- Therapist: “Who would measure something?”
- Patient: “Carpenter”
- The answer should be specific to the verb. It can also be personal to the patient. For example, “My mom measures”
- Therapist: “What’s something the carpenter might measure?”
- Patient: “Wood”
- The answer should be specific to the verb. For example, “Carpenter measures wood”
- The 3 scenarios shouldn’t be too similar. Give cues as needed
- Here are 3 different-enough scenarios for the verb ‘measure’:
- Carpenter measures wood
- My mom measures fabric
- The chef measures ingredients
Step 2: VNeST Protocol
The patient reads aloud the 3 sentences they just made.
This can be independent reading or with assistance (e.g., choral reading, read and repeat).
Step 3: VNeST Protocol
- The patient chooses one of the 3 scenarios they came up with
- “My mom measures fabric”
- Therapist: “Where does your mom measure fabric?”
- Patient: “Table”
- Therapist: “When does your mom measure fabric?”
- Patient: “At night”
- Therapist: “Why does your mom measure fabric?”
- Patient: “Her job”
- “My mom measures fabric at the table”
- “My mom measures fabric because it’s her job”
- “My mom measures fabric at night”
- Or they can put it all together, “My mom measures fabric at the table at night because it’s her job”
Step 4: VNeST Protocol
- Before the session, prepare 12 sentences containing the target verb:
- 3 sentences will be correct
- 3 sentences will have the wrong agent
- 3 sentences will have the wrong patient
- 3 sentences will have the agent and patient switched
Example Sentences
- Correct: The carpenter measures wood. The chef measures ingredients. The designer measures fabric.
- Wrong agent: The dentist measures wood. The policeman measures chemicals. The farmer measures clothes.
- Wrong patient: The carpenter measures time. The scientist measures criminals. The designer measures teeth.
- Switched agent and patient: The wood measures the carpenter. The chemical measures the scientist. The clothes measure the designer.
Step 5: VNeST Protocol
- Clear the table
- Ask for the target verb again
- Therapist: “What verb were you just working on?”
- Patient: “Measure”
- Therapist: “Tell me again who might measure and what would they measure?”
- Patient: “My mom measures fabric”
This isn’t a memory task. If they can’t remember, end on a high note and don’t push for recall.
V-NeST Resources
- VNeST Protocols Medbridge Course by Dr. Lisa Edmonds
- Free VNeST verb list (PDF)
- VNeST Tutorial by Dr. Edmonds
- Aphasia Workbook for more aphasia therapy resources
- Dr. Edmond’s recent lecture on VNeST:
What’s The Goal?
Intention manipulation is a treatment approach that aims to recruit the right hemisphere of the brains of patients with nonfluent aphasia.
Its goal is to improve expressive language.
Although intention manipulation is not a stand-alone aphasia treatment, preliminary research suggests that it may shift some language production to the right side of the brain (Crosson, 2008).
Intention Manipulation Protocol
To do intention manipulation, the patient completes a left-hand movement during a naming task.
- The patient completes a complex left-hand movement
- For example, they open the lid of a box and then squeeze a rubber ball
- After the hand movement, ask them to name a target picture
- If correct, proceed to the next target picture
- If incorrect, the patient repeats the target word and then completes a different left-hand movement (e.g. making a circle with the left hand)
3. Semantic Feature Analysis (SFA)
What’s The Goal?
Semantic feature analysis helps people with anomia retrieve nouns.
It does this by teaching patients a word-retrieval process.
Research shows that SFA leads to significant improvement in word retrieval for the nouns that were practiced, with some generalization (Maddy, 2014; Efstratiadou, 2018).
Materials
You’ll need a chart and picture cards to do semantic feature analysis.
Download the free Naming Photos & Visual Scenes PDF for full-color images.
Semantic Feature Analysis Protocol
- Present the semantic feature analysis chart
- Present a picture of the target noun
- Ask the patient to name the picture
- Whether they name it correctly or not, keep going!
- One by one, prompt them to name the 6 semantic features on the chart. Cue as needed
- Write down the features as the patient names them
- After they’ve named all 6 features, ask them to name the picture again
- Summarize the chart to prompt a correct answer: “It’s a big vehicle that floats on water, looks like a canoe, and is used for fishing”
- Use one set of 10 pictures per session and rotate through the sets until the patient achieves 80% accuracy independently for each set
To help your patient internalize this word-retrieval process, go through the semantic features in the same order, every time.
This repetition takes advantage of their procedural memory.
Of course, be flexible and go with the patient’s flow! But then return to the same order to help cement the process in their minds.
What Are The 6 Semantic Features?
1. Association. What does it remind you of?
2. Group. What type of thing is it?
3. Action. What does it do?
4. Properties. What does it look/taste/sound/feel like? (color, shape, size, etc)
5. Location. Where do you find it?
6. Use. What is it used for?Semantic Feature Analysis Resources
- Semantic feature analysis chart
- Aphasia picture cards
- Naming Therapy App by Tactus Therapy
- Semantic Feature Analysis Treatment for Aphasic Word Retrieval Impairments: What’s in a Name?
4. Phonological Components Analysis (PCA)
What’s The Goal?
The goal of phonological components analysis is to improve expressive language.
A handful of small studies found that PCA improves naming deficits and may generalize outside of therapy (Leonard, 2008, 2014; van Hees, 2013).
PCA helps patients come up with a word by first describing the phonological features of the word.
Sound familiar? PCA is modeled after semantic feature analysis.
Like SCA, you’ll use a chart with the target picture placed in the middle.
What Are The 5 Phonological Components?
1. Rhyming Word. What does the word rhyme with?
2. First Sound. What’s the first sound in the word?
3. Another Word. What’s another word that starts with that sound?
4. Final Sound. What’s the last sound in the word?
5 Number of Syllables. How many syllables does the word have?Materials
You’ll need a PCA chart and picture cards to do phonological feature analysis.
Phonological Components Analysis Protocol
- Present and introduce the PCA chart
- Present the target picture
- Ask the patient to name the picture
- One by one, ask them to name the 5 phonological components
- Write the components on the chart as the patient names them
- If the patient can’t generate a component, show and read a list of up to 3 choices for that component
- Again, ask the patient to name the picture
- Summarize the chart to prompt a correct answer
- For example, “Starts with ‘s’ and ends with ‘e’ or ‘y’, rhymes with ‘kitty'”
- Use one set of 10 pictures per session, and rotate through the sets until the patient achieves 80% accuracy independently for each set.
PCA Resources
- Free PCA chart
- Aphasia Picture Cards
Repetition Aphasia Treatment Approaches
1. Melodic Intonation Therapy (MIT)
What’s The Goal?
Melodic Intonation Therapy is an evidence-based treatment for expressive language deficits.
Over a century ago, therapists observed that some people with aphasia can still sing (‘intone’) words that they can no longer speak.
MIT was developed based on this observation.
A recent systematic review found that MIT improved repetition and increased phrase length in people with non-fluent aphasia (Zhang, 2022).
Use MIT to guide patients from singing short, simple phrases to speaking them.
Modeling you, the patient will repeat a word, tapping pattern, and intonation pattern.
Best Candidates for MIT
The best candidates for MIT treatment are patients with (from Norton, 2009):
- a unilateral, left-hemisphere stroke
- poorly articulated, nonfluent, or severely restricted speech output
- ablility to produce some intelligible words while singing familiar songs
- poor repetition, even for single words
- moderately well-preserved auditory comprehension
- poorly articulated attempts at speech
- good motivation, emotional stability, and good attention span
Melodic Intonation Therapy Steps
Below is a beginner’s MIT protocol, summarized from Norton et al. (2009).
Read their article for intermediate and advanced protocols.
- Show the phrase. Show the patient the target phrase
- Hum the phrase. Hum at a rate of 1 syllable per second
- Use a higher-pitched note on the stressed syllable or word
- Sing the phrase and tap. Sing the phrase twice . While singing, you tap the patient’s left hand on each syllable
- Again, sing a higher-pitched note on the stressed syllable or word
- For example, with the word “apple,” the first syllable “ah” will be high-pitched and the second syllable “ple” will be low-pitched
- Sing together. Sing the phrase in unison with your patient while tapping the patient’s left hand on each syllable
- Fade out. Continue to sing the phrase together with the patient while tapping their left hand. Gradually fade your singing
- Now, the patient is singing alone while you tap their left hand (don’t give verbal or oral/facial cueing)
- Take turns singing. You sing the phrase while the patient listens. Immediately after, the patient sings the phrase alone, assisted only by your hand-tapping
- Patient sings alone. Immediately after their correct repetition, ask, “What did you say?” Provide hand-tapping as the patient sings the target phrase
- Repeat. Repeat a new phrase
MIT Resources
What’s The Goal?
With this approach, you help your patient create scripts that will improve conversations in their daily life. An example is a script to order pizza over the phone.
For example scripts, see the Rehabilitation Institute of Chicago’s Scripted Conversation Templates (in the ‘Supplementary Materials’).
Each of their scripts has 5 levels of difficulty, based on aphasia severity.
Script Training Protocol
- Work with your patient to make 3 scripts that would improve their daily conversations. Each should be useful for your patient and the right level of difficulty
- Each script should have lines for both your patient and the conversation partner
- For example, for a script to pay a credit card bill over the phone, write lines for both the patient and the customer service agent
- Each script should have 10 turns
- During their turn, the patient will respond to what the conversation partner just said
Up The Challenge
To up the challenge, increase the word and sentence length of the scripts.
For example, “I want to pay my bill,” can be replaced with, “I’m calling to pay my September cell phone bill.”
You can also increase semantic difficulty. For example, the word “help” can be replaced with “support,” “guidance,” or “assistance.”
Script Training Templates
- University of Chicago’s Scripted Conversation Templates (in the ‘Supplementary Materials’)
2. Sentence Production Program for Aphasia (SPPA)
What’s The Goal?
The goal of SPPA is to improve expressive language.
SPPA is sold by PRO-ED. It uses story completion tasks to elicit target sentences from a patient.
How To Do SPAA
You’ll use the SPAA picture cards with action scenes. Then ask your patient to repeat sentences about each scene using a target sentence structure.
Each target sentence has two levels of difficulty: Level A and Level B.
The patient must complete all Level A sentences at 90% accuracy before advancing to Level B.
Level A Sentences
You’ll read a story that has the target sentence. For example,
Andy is shopping at the mall. He tries on a blue shirt that he likes, but the price tag is missing. Andy asks an employee, “How much does the shirt cost?”
You ask the patient, “What does Andy ask the employee?”
Correct answer: “How much does the shirt cost?”
Level B Sentences
You ask the patient, “When Andy doesn’t know the shirt’s price, what does Andy ask?”
Then, you’ll have the patient use the same sentence structure (e.g. “How much does the shirt cost?”) to complete different narratives.
SPPA Resources
- SPPA PRO-ED Purchase Page
- Sentence production in rehabilitation of agrammatism: A case study
3. Melodic Intonation Therapy
Syntax Production
1. Response Elaboration Training (RET)
What’s The Goal?
The goal of response elaboration training is to increase the number of content words that a patient with aphasia says during a conversation.
Content words include nouns, verbs, adverbs, pronouns, adjectives, and prepositions.
Unlike other aphasia treatment approaches, RET has no specific rules to follow.
Instead, you’ll encourage your patient to speak longer utterances by:
- Confirming their responses and then
- Chaining onto (elaborating) their responses
Response Elaboration Training Protocol
Use RET with visual or auditory prompts.
When using a visual prompt, it’s best to use simple pictures that have an action for your patient to name.
- Show the patient a picture. Say, “Tell me as much as you can about this picture”
- For example, there’s a picture of a man brushing his teeth. The patient says, “Man…brushing”
- Positively confirm the patient’s response, then expand their utterance
- “That’s correct. The man is brushing his teeth”
- Ask wh-questions to elicit more information
- “What is he using to brush his teeth?”
- Positively reinforce what they say, then provide a more complete sentence for them to imitate
- “Yes! He’s brushing his teeth with a toothbrush. Can you repeat that whole sentence?”
- Keep elaborating with more wh-questions, as appropriate
When using an auditory prompt, choose a daily task that’s familiar to your patient and ask them to describe how to do it.
- Ask the patient the steps to doing a task
- For example, “Describe in detail the steps to feeding your cat.”
- Positively confirm what they say, then ask for more information
- “That’s right. Let’s pretend that I’ve never fed a cat before. Explain to me step-by-step what to do in detail.”
- Give your patient enough time to generate a longer response. After they stop speaking, ask, “Is there anything else?”
- Repeat this process with additional auditory prompts
Read Response Elaboration Training Made Easy for a step-by-step guide and goals.
Response Elaboration Training Resources
- Picture cards and visual scenes
- A Qualitative Analysis of Response Elaboration Training Effects
2. Treatment of Underlying Forms (TUF)
Illustration copyright © 2023 Vince Aparo
What’s The Goal?
The goal of treatment of underlying forms is to help people with agrammatic aphasia to say and understand more complex sentences.
TUF does this by breaking down a sentence into its parts.
Research shows that TUF generalizes outside of treatment, improves people’s ability to say sentences, and improves sentence comprehension (Thompson & Shapiro, 2005).
For more severe comprehension deficits, read:
How Does TUF Work?
TUF uses word cards and pairs of picture cards to help patients build sentences.
Although there are several TUF treatment protocols, we’ll cover just one: the Object-extracted wh-questions (wh movement).
You can learn how to do the other protocols, passive sentences, and object-cleft sentences by purchasing the TUF manual from Northwestern University.
Preparing for TUF Treatment
1. Gather Pairs of Picture Cards
For TUF treatment, you’ll use a pair of picture cards. Each picture should have an action with both a subject and an object.
The pair of picture cards will have the same action. But the object and subject will be reversed.
- In the example pair above, the shared action is kisses. While the subject and object of the action are reversed.
- In Picture 1, the subject is the girl and the object is the boy. The girl kisses the boy.
- In Picture 2, the subject is the boy and the object is the girl. The boy is now kissing the girl.
Gather 10 pairs of picture cards.
2. Write Down the Subject and Object
- On separate notecards, write down the subject and the object.
- Do this for each of the 10 pairs of pictures.
3. Write Down the Verb that Describes the Action
- On separate notecards, write the verb that describes the action happening in the picture pair.
- Do this for each of the 10 pairs of pictures.
4. Write These Words/Symbol on 8 Notecards
On 8 separate notecards, write the following:
Treatment of Underlying Forms Protocol
Here are the steps to using a pair of picture cards to say sentences.
We’ll use the example of the target sentence the girl is kissing the boy.
You will start with the picture of the semantically reversed pair (the boy is kissing the girl). And move the patient through sentences until they arrive at the target sentence.
1. Put Down the Reversed Picture
2. Put Down These Notecards: Subject, Object, Verbs, WHO (and/or WHAT), and ?
- Place the boy (subject notecard), is, kissing (verb notecards), the girl (object notecard) in the correct order.
- Place the who, ? (and/or what) notecards above the sentence.
- Point to the verb card and say, “This is kissing. It is the action of the sentence.”
- Point to the subject card and say, “This is the boy. He is the person doing the kissing.”
- Point to the object card and say, “This is the girl. She is being kissed”.
- Next, you’ll replace the object with either who or what.
3. Replace the Object with WHO (or WHAT)
- Say, “The object is who (or what), and they are being kissed.”
- Place ? at the end of the sentence, then ask the patient to read (or repeat) the new sentence.
- For example: the boy, is, kissing, who, ?
4. Move ‘Is’ to the Beginning of the Sentence (Inverse the Subject and Auxiliary Verb)
is, the boy, kissing, who, ?
5. Move the Wh-morpheme (WHO) to the Sentence-Initial Position
Ask the patient to read (or repeat) the resulting question: who, is, the boy, kissing, ?
6. Re-arrange the Word Cards to Make a Declarative Sentence
- Re-arrange the word cards to make a declarative sentence again, just like in step 1.
- But now the girl is the subject and the boy is the object.
- The notecard positions are now switched to the target sentence (the girl is kissing the boy).
7. Replace the Semantically Reversed Picture with the Target Picture
Next, you’ll place down the target picture (the girls kissing the boy).
8. Have Them Complete Steps 2-6
- Have your patient complete steps 2-6 with the target picture, switching the positions of the object and subject notecards.
- Provide assistance, as needed.
9. Return to Step 1 With a New Picture Pair
TUF Resources
- TUF manual, picture cards, and word cards
- Treatment of Underlying Forms in a discourse context
- Treatment of Underlying Forms: A linguistic Specific Approach for Sentence Production Deficits in Agrammatic Aphasia (Book)
3. Sentence Production Program for Aphasia (SPPA)
Auditory Comprehension Treatment Approaches
1. Schuell’s Stimulation Approach (SSA)
What’s The Goal?
The goal of Schuell’s stimulation approach is to improve receptive and expressive language.
It aims to reorganize language that was disrupted by brain damage through the use of sensory stimulation that is strong, controlled, and intensive.
SSA is not a protocol. Instead, it aims to make aphasia therapy more effective by encouraging therapists to use the best sensory stimuli for each patient.
Materials for SSA
What Are The Principles of SSA?
- Use the right level of sensory stimulation
- Use repetitive sensory stimulation
- Each stimulus should elicit a response
- Patient responses should be elicited, NOT forced or corrected. If you don’t elicit a response, give more stimulus (vs correction or instruction)
- Elicit a maximum number of responses (you should have lots of responses since you’re giving lots of stimuli)
- Give reinforcement and feedback about accuracy. Observe your patient to know how much feedback is most motivating and encouraging
- Have a plan. Treatment should be systematic and intensive
- Start with familiar and relatively easy tasks. Allow patients to “warm up” and build confidence
- Use abundant and varied treatment materials. Make sure they’re simple and relevant to the patient’s needs. Avoid reusing limited content; it’s frustrating. The content of the material is less important than how you approach treatment
- New materials should chain onto the familiar. This way, the patient focuses on language processing—not on learning new content
How To Do Schuell’s Stimulation Approach
Below is a list of specific stimuli that can improve aphasia treatment (Coelho, 2008).
- Reduce background noise
- Use realistic, colored images
- Images shouldn’t be ambiguous. If the image is ambiguous, consider pairing it with an object that sheds light on what it’s function is
- For example, pair the target word “mug” with a coffee pot.
- Operative objects are easier to name. Operative objects are distinct, have multiple recognizable forms, and are firm to the touch
- A rock is operative
- Objects that conjure the senses are easier to name
- A rock feels rough, looks brown, is dense, etc.
- Use large print. Patients respond better to large print, even those without vision loss or visual processing deficits
- Provide face-to-face treatment. Patients respond better when interacting face-to-face versus listening to or watching recordings
- Use semantically different words. It’s harder for patients to accurately name semantically similar pictures
- A chair, table, and a stool are semantically similar
- Use phonetically and visually different words. Patients more easily confuse words that are phonetically similar (horse vs house) or visually similar (E vs F)
- Use an image with few alternative responses, to improve naming accuracy
- For example, the image of a shoe has fewer alternative responses than the image of a landscape
- Combine multiple types of sensory stimulation to improve the speed and accuracy of naming tasks
- These include auditory cues with visual, gestural, or tactile cues (tracing a letter on a patient’s hand)
- Use massed practice (lots of repetition) of small sets of words that are semantically or phonetically related.
- Combine massed practice with constraint-induced language therapy
- For example, the patient is required to use only language and not gestures or compensatory strategies like circumlocution
- Speak slower and add pauses
- Use shorter auditory messages to improve comprehension and retention. Single words are easier to understand than phrases or sentences
- Use shorter words (one syllable and less than 4-5 letters) to increase comprehension
- Use redundant sentences and paragraphs
- Choose cues and prompts based on where each patient’s language breaks down (semantic level, phonological level, etc.)
- Use multisensory, graded cues and prompts
- Multisensory cues include letter tracing, writing words, gestures, and auditory and visual cues
- Graded cues can progress from maximal to minimal cues (word repetition graded down to asking what the object’s function is) or visa-versa
- Use semantic cues to improve naming accuracy
- “This is something you wear on your head,” for hat. See Semantic Feature Analysis described above
- Phonological cues improve naming accuracy
- “It starts with ‘h’, for hat.” See Phonological Component Analysis described above
- Frequency improves comprehension at the word, phrase, and sentence levels
- Word frequency is not universal—consider whether the word or phrase is actually common for your patient, given their culture and life experiences
- Use non-abstract words
- Vary parts of speech and semantic categories
- Parts of speech include nouns, verbs, and adjectives
- Add context. These are clues that help the patient guess what the target word means
- Focus on the main ideas versus the details
- Talk naturally
- Use scripts that are salient to the patient’s life
- Use stressed words (see Melodic Intonation Therapy)
- Progress from the easiest tasks to the hardest tasks
- Screen for hearing loss. Be aware of potential auditory deficits and how they impact language
- Be patient and present. Patients pick up on negative emotional cues, even subtle ones
- Give lots of opportunities for success.
- Encourage plenty of rest and breaks
- Respect signs of fatigue and encourage plenty of rest and breaks. Try to schedule therapy when your patients aren’t as tired
Schuell’s Stimulation Approach Resources
- 55 Aphasia Treatment Activities (fluent & nonfluent)
- Aphasia Workbook
- Schuell’s Stimulation Approach to Rehabilitation (Book chapter)
