Professional Documents
Culture Documents
In This Issue
Guest Editors Column by Candace Vickers..........................................................................7677
Tutorial for Verb Network Strengthening Treatment (VNeST): Detailed Description of the
Treatment Protocol with Corresponding Theoretical Rationale by Lisa A. Edmonds...............7888
74
Disclaimer of warranty: The views expressed and products mentioned in this publication may not reflect
the position or views of the American Speech-Language-Hearing Association or its staff. As publisher, the
American Speech-Language-Hearing Association does not warrant or guarantee the accuracy, completeness,
availability, merchantability, fitness for a particular purpose, or noninfringement of the content and
disclaims responsibility for any damages arising out of its use. Advertising: Acceptance of advertising does
not imply ASHAs endorsement of any product, nor does ASHA accept responsibility for the accuracy of
statements by advertisers. ASHA reserves the right to reject any advertisement and will not publish
advertisements that are inconsistent with its professional standards.
ASHA Board of Directors Board Liaisons: Donna Fisher Smiley, Vice President for Audiology Practice
Gail J. Richard, Vice President for Speech-Language Pathology Practice
ASHA Production Editor: Victoria Davis
ASHA Advertising Sales: Pamela J. Leppin
ASHA Board of Directors: Elizabeth S. McCrea, President Judith L. Page, President-Elect Patricia A.
Prelock, Immediate Past President Donna Fisher Smiley, Vice President for Audiology Practice Perry F.
Flynn, Speech-Language Pathology Advisory Council Chair Wayne A. Foster, Audiology Advisory Council
Chair Howard Goldstein, Vice President for Science and Research Carlin F. Hageman, National Student
Speech Language Hearing Association (NSSLHA) National Advisor Carolyn W. Higdon, Vice President for
Finance Barbara J. Moore, Vice President for Planning Robert E. Novak, Vice President for Standards
and Ethics in Audiology Gail J. Richard, Vice President for Speech-Language Pathology Practice Shari B.
Robertson, Vice President for Academic Affairs in Speech-Language Pathology Theresa H. Rodgers, Vice
President for Government Relations and Public Policy Barbara K. Cone, Vice President for Academic Affairs
in Audiology Lissa A. Power-deFur, Vice President for Standards and Ethics in Speech-Language Pathology
Arlene A. Pietranton, Chief Executive Officer (ex officio to the Board of Directors)
75
References
Edmonds, L. A., & Babb, M. (2011). Effect of verb network strengthening treatment in moderate-to-severe
aphasia. American Journal of Speech-Language Pathology, 20, 131145.
Leach, E., Cornwell, P., Fleming, J., & Haines, T. (2010). Patient-centered goal setting in a subacute
rehabilitation setting. Disability and Rehabilitation, 32, 159172.
Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001) Training volunteers as
conversation partners using Supported conversation for adults with aphasia (SCA): A controlled trial.
Journal of Speech, Language and Hearing Research, 44, 624638.
Rowden-Racette, K. (2013, September 01). In the limelight: Guides for the long journey back. The ASHA Leader.
77
Participants
It is beyond the scope of this article to provide a comprehensive review of VNeST studies.
However, a few pertinent details regarding participant outcomes are provided (see original articles
for more information). Three studies investigated VNeST in 17 people with aphasia (10 male)
(Edmonds & Babb, 2011; Edmonds et al., 2014; Edmonds et al., 2009), and one study provided
a computerized version of VNeST (VNeST-C) via teletherapy to two males (Furnas & Edmonds,
2014). All participants were at the chronic stage of aphasia ( 9 months) and most had moderately
severe aphasia. Two participants had severe aphasia (Edmonds & Babb, 2011). Five participants
were diagnosed with anomic aphasia (all mild), 5 with conduction aphasia (one with substantial
jargon), 4 with transcortical motor aphasia, 2 with Brocas aphasia (both severe), and 1 with
Wernickes aphasia. The participants who received VNeST-C had moderate-severe Brocas aphasia
with mild to moderate apraxia of speech (AOS) and mild anomic aphasia with moderate-severe
AOS.
Overall, there has been replicated improvement and generalization of lexical retrieval
abilities in confrontation naming of nouns and verbs, sentence production and discourse, as well
as clinically significant improvement on the Western Aphasia Battery (WAB; Kertesz, 1982, 2006).
Further, significant improvement on reports of functional communication from family members
(on the Communicative Effectiveness Index [CETI; Lomas et al., 1989]) has been reported in 11
of 11 participants for whom we have those data. While every participant did not improve on all
outcome measures, all exhibited improvement and generalization to a number of outcome measures.
Thus, it is reasonable to suggest that VNeST may be appropriate for participants who generally
fit within the parameters of these participants. However, keep in mind the following: (a) We have
only tested one person with Wernickes aphasia (who also had a severe verb impairment). Her
improvement was encouraging, with improvements on the WAB, verb and noun naming, informative
and complete utterances in discourse, and the CETI (per her husbands ratings; Edmonds et al.,
2014); (b) We have excluded people with greater than mild to moderate AOS except in the
computerized VNeST study, where typing was included as part of the treatment. Even though
VNesST-C participants improved in spoken and written modalities, we cannot make generalized
clinical recommendations at this time; and (c) Diagnosis of global aphasia has also been an
exclusionary variable, because VNeST requires better comprehension than is often seen in persons
with global aphasia.
Dosage
In all VNeST studies, we have provided treatment 2 times/week for 1.52 hours per session
(though VNeST-C was delivered 3 times/week for 2 hours each session). In our most recent study,
we controlled dosage to 10 weeks of treatment with 10 verbs for approximately 3.5 hours of
treatment per week (35 hours total). The group of 11 participants exhibited improvement across
outcome measures (Edmonds et al., 2014) and examination of the slopes of improvement on
sentence probes administered throughout treatment revealed that participants did not plateau
79
Abstract
Verb Network Strengthening Treatment (VNeST) is a theoretically motivated aphasia
treatment that has resulted in promising generalization to untrained sentences and
discourse in persons with aphasia. As with all speech and language therapies, it is critical
that clinicians understand the theoretical motivation behind VNeSTs protocol in order to
make informed decisions during provision of the treatment. This article provides a detailed
VNeST tutorial, including characteristics of participants who might be suitable, dosage
information, and detailed instructions for each treatment step, including rationale, cueing
guidelines, and frequently asked questions. Further guidance is provided regarding verb
selection, and a score sheet is included for easy recording of responses and cueing levels.
Aphasia is an acquired language disorder, primarily caused by stroke, which affects
language production and comprehension. Anomia, or difficulty retrieving words, is a pervasive
symptom of aphasia that can negatively impact basic communication functions such as interacting
with family and co-workers, talking on the phone, and expressing needs, wants, and emotions.
A fundamental challenge in aphasia treatment is to achieve improved lexical retrieval in sentences
and discourse, particularly for untrained words in untrained language contexts (i.e., generalization).
Verb Network Strengthening Treatment (VNeST) is a theoretically motivated aphasia treatment
that has resulted in promising generalization to sentences and discourse in persons with aphasia
(Edmonds & Babb, 2011; Edmonds, Nadeau, & Kiran, 2009; Edmonds, Mammino & Ojeda, 2014;
Furnas & Edmonds, 2014). There are a number of treatment steps in VNeST, and each has a
specific purpose with regard to the treatments theoretical foundation. Therefore, the purpose of
this article is to provide clinicians and researchers with a tutorial that details the logistics and
rationale of each treatment step. Suggestions regarding selection and development of treatment
and testing materials are also provided.
VNeST is based on theories of event memory that conceive of neurological networks of verbs
and related nouns (i.e., verb networks) that wire together through use and world knowledge (e.g.,
Ferretti, McRae, & Hatherell, 2001). The nouns related to the verbs in these proposed networks
are called thematic roles, because they relate to the verb with regards to who is performing the
action (agent), the receiver of the action (patient), the location of the action, and the instrument of
the action (e.g., The plumber [agent] is fixing [verb] the sink [patient] in the bathroom [location] with
a wrench [instrument]). Research has indicated that verbs and their related thematic roles are
neurally co-activated such that agents and patients prime/facilitate activation of related verbs
(Edmonds & Mizrahi, 2011; McRae, Hare, & Ferretti, 2005) and vice versa (Edmonds & Mizrahi,
2011; Ferretti, McRae, & Hatherell, 2001). There is also bidirectional neural co-activation between
verbs (e.g., slicing) and their instruments (e.g., knife) (Ferretti, McRae, & Hatherell, 2001; McRae
et al., 2005) and priming from locations (e.g., restaurant) to related verbs (e.g., eating; Ferretti
et al., 2001).
78
82
Materials
Treatment Materials
VNeST was designed to be low tech, so that it could be administered in any setting. At
minimum, all that is needed is a pen and paper. However, materials can be prepared ahead of time
on cardstock (we cut index cards into thirds) for repeated use or use a clipboard-sized erasable
white board to write responses. The cards provide the benefit of being manipulable, but a whiteboard
or sheets of paper should work just as well.
There are a variety of verbs that can be used in treatment. One basic requirement is that
the verb is a two-place verb (takes 2 arguments; e.g., a subject and object; The waiter folds the
napkin.). Thus, one-place verbs, which only require one argument (e.g., The boy swims.) are not
recommended. However, our research has shown that training two-place verbs often results in
improvement to one-place verbs, so one-place verbs and/or sentence production can be evaluated
as a generalization measure. See Appendix A for suggestions on verb selection.
Outcome Measures
The outcome measures chosen to evaluate improvement should reflect a participants
treatment goals. Lexical retrieval abilities across a range of tasks, including confrontation naming
for nouns and verbs, sentence production, and discourse should be examined. You can also
evaluate aphasia severity (e.g., WAB-R), sentence comprehension, and functional communication.
The sentence probe pictures used in VNeST studies are not currently available. However, we have
also used the Northwestern Assessment of Verbs and Sentences (NAVS; Thompson, 2011) to
evaluate sentence production and comprehension as well as verb naming. The NAVS can be found
online (Flintbox, 2010). For noun naming, the Philadelphia Naming Test (PNT) is downloadable
free-of-charge online (Moss Rehabilitation Research Institute, 2013), complete with answer sheets
and scoring information. There are many ways to analyze discourse. One option is the stimuli
and analysis methods from Nicholas and Brookshire (1993), which can be found on the ASHA
website. In addition to the outcome variables described in Nicholas and Brookshire, we have
examined complete utterances, which consider both the completeness (contains a subject, verb,
and object [when required]) and relevance (relevant to the topic) of utterances (see Edmonds et al.,
2009; Edmonds et al., 2014). Evaluating the relative improvement of relevance and completeness
is also informative.
Treatment Protocol
See Appendix B for an example of a VNeST answer sheet.
Step 1. Generation of Multiple Scenarios Around the Trained Verb
Detailed Instructions. Set down the cards with the words who and what written on
them (see Figure 1). Point to each card and tell the participant that these cards say who and
what. Then place the card with the verb written on it between the who and what cards and
ask Who can/might (verb) something/someone? In this example, we will use the verb drive. If
the participant does not understand the word who, then you can say, Can you think of a person
who drives something? If the participant is able to independently produce a plausible response
(e.g., chauffeur, my wife, taxi drive), write the word on a blank card and set it under the who card
(see Figure 1).
80
Treatment Settings
VNeST has only been evaluated in outpatient sessions with trained clinicians. We have not
trained family members or volunteers to conduct VNeST; therefore, we do not have information
on how participants respond in these cases. Provision of VNeST requires an understanding of the
treatments principles, including feedback. Thus, if family members are trained to do VNeST, they
should be highly involved in treatment sessions with the clinicians first. The information in this
article may be helpful for home use/practice and training of volunteers or family members as well.
References
Black, M., & Chiat, S. (2003). Nounverb dissociations: A multi-faceted phenomenon. Journal of
Neurolinguistics, 16, 231250.
Edmonds, L. A., & Babb, M. (2011). Effect of Verb Network Strengthening Treatment in moderate-to-severe
aphasia. American Journal of Speech-Language Pathology, 20, 131145.
Edmonds, L. A., & Mizrahi, S. (2011). Online priming of verbs and thematic roles in younger and older
adults. Aphasiology, 25(12), 14881506.
Edmonds, L. A., Mammino, K., & Ojeda, J. (2014). Effect of Verb Network Strengthening Treatment (VNeST)
in persons with aphasia: Extension and replication of previous findings. American Journal of Speech
Language Pathology. doi:10.1044/2014_AJSLP-13-0098
Edmonds, L. A., Nadeau, S., & Kiran, S. (2009). Effect of Verb Network Strengthening Treatment (VNeST) on
lexical retrieval of content words in sentences in persons with aphasia. Aphasiology, 23(3), 402424.
Ferretti, T. R., McRae, K., & Hatherell, A. (2001). Integrating verbs, situation schemas, and thematic role
concepts. Journal of Memory and Language, 44, 516547.
Flintbox. (2010). Northwestern assessment of verbs and sentences (NAVS). Retrieved from https://flintbox.
com/public/project/9299/
Furnas, D. W., & Edmonds, L. A. (2014). The effect of Computer Verb Network Strengthening Treatment on
lexical retrieval in aphasia. Aphasiology, 28, 401420.
Kertesz, A. (1982). Western Aphasia Battery. Austin, TX: Pro-ed.
Kertesz, A. (2006). Western aphasia batteryRevised. Austin, TX: Pro-ed.
Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The communicative
effectiveness index: Development and psychometric evaluation of a functional communication measure for
adults aphasia. Journal of Speech and Hearing Disorders, 54, 113124.
McRae, K., Hare, E., & Ferretti, T. R. (2005). A basis for generating expectancies for verbs from nouns.
Memory and Cognition, 33(7), 11741184.
Moss Rehabilitation Research Institute. (2013). Philadelphia naming test (PNT). Retrieved from http://www.
mrri.org/philadelphia-naming-test
Nicholas, L. E., & Brookshire, R. H. (1993). A system for quantifying the informativeness and efficiency of the
connected speech of adults with aphasia. Journal of Speech and Hearing Research, 36, 338350.
Rogalski, Y., Edmonds, L. A., Daly, V. R., & Gardner, M. J. (2013). Attentive Reading and Constrained
Summarization (ARCS) discourse treatment for anomia in two women with moderate-severe Wernickes type
aphasia. Aphasiology, 27, 12321251.
Thompson, C. K. (2011). The Argument Structure Production Test/The Northwestern Assessment of Verbs and
Sentences. Northwestern University.
Webster, J., Franklin, S., & Howard, D. (2004). Investigating the sub-processes involved in the production of
thematic structure: An analysis of four people with aphasia. Aphasiology, 18, 4768.
86
82
83
84
Goals that map very clearly and specifically to the evaluation data are encouraged and
even required by most rehabilitation companies and facilities within their documentation systems
to facilitate reimbursement. Undeniably, the links between the initial evaluation data to the goal
and desired outcomes in Table 2 are straightforward, and because of their clarity and obvious
measurement, they are likely to be reimbursed.
Will these goals affect Mrs. Cs participation in life? Although initial performance on
impairment-focused assessments, like standardized aphasia batteries, may be related to activity
participation, change on impairment-based assessments is not necessarily related to change on
activity participation (Ross & Wertz, 1999, 2002). So, focusing our intervention on a specific
impairment, like impaired auditory comprehension, does not necessarily mean that the client will
now be equipped to participate in life activities.
If we want to increase the likelihood that we will facilitate life participation in our clients,
we have to assess current opportunities for improved participation and focus our intervention
efforts on those. Lets use Mrs. Cs performance on the Communication Activities of Daily Living
(CADL-2; Holland, Frattali, & Fromm, 1999) as an example. This assessment uses role play to
sample a number of activities that are likely to be relevant to a person with aphasia residing in
the community, such as shopping, going to a doctors appointment, ordering from a restaurant
menu, understanding a bus schedule, and filling out forms. The CADL-2 overall score for Mrs. C
was 17%. Since points on most items of the CADL-2 are given based on producing a fully
communicative message regardless of modality, her overall score tells us that Mrs. C is not able
to use many communication modalities very effectively to perform in these role-play activities.
We can analyze specific items within the CADL-2 that correspond to specific activities as
an informal way to track communicative performance. For example, we can analyze Mrs. Cs
ability to provide personal information such as name, address, and medical information with
items #36 of the CADL-2. Assuming that providing personal information is a valuable activity for
Mrs. C, then this can be targeted with a treatment goal. ASHA NOMS levels can be assigned
based on the likelihood that Mrs. C will use spoken language expression or writing to convey the
personal information. Possible goals derived from activities assessed on the CADL-2 are shown in
Table 3.
91
Treatment Settings
VNeST has only been evaluated in outpatient sessions with trained clinicians. We have not
trained family members or volunteers to conduct VNeST; therefore, we do not have information
on how participants respond in these cases. Provision of VNeST requires an understanding of the
treatments principles, including feedback. Thus, if family members are trained to do VNeST, they
should be highly involved in treatment sessions with the clinicians first. The information in this
article may be helpful for home use/practice and training of volunteers or family members as well.
References
Black, M., & Chiat, S. (2003). Nounverb dissociations: A multi-faceted phenomenon. Journal of
Neurolinguistics, 16, 231250.
Edmonds, L. A., & Babb, M. (2011). Effect of Verb Network Strengthening Treatment in moderate-to-severe
aphasia. American Journal of Speech-Language Pathology, 20, 131145.
Edmonds, L. A., & Mizrahi, S. (2011). Online priming of verbs and thematic roles in younger and older
adults. Aphasiology, 25(12), 14881506.
Edmonds, L. A., Mammino, K., & Ojeda, J. (2014). Effect of Verb Network Strengthening Treatment (VNeST)
in persons with aphasia: Extension and replication of previous findings. American Journal of Speech
Language Pathology. doi:10.1044/2014_AJSLP-13-0098
Edmonds, L. A., Nadeau, S., & Kiran, S. (2009). Effect of Verb Network Strengthening Treatment (VNeST) on
lexical retrieval of content words in sentences in persons with aphasia. Aphasiology, 23(3), 402424.
Ferretti, T. R., McRae, K., & Hatherell, A. (2001). Integrating verbs, situation schemas, and thematic role
concepts. Journal of Memory and Language, 44, 516547.
Flintbox. (2010). Northwestern assessment of verbs and sentences (NAVS). Retrieved from https://flintbox.
com/public/project/9299/
Furnas, D. W., & Edmonds, L. A. (2014). The effect of Computer Verb Network Strengthening Treatment on
lexical retrieval in aphasia. Aphasiology, 28, 401420.
Kertesz, A. (1982). Western Aphasia Battery. Austin, TX: Pro-ed.
Kertesz, A. (2006). Western aphasia batteryRevised. Austin, TX: Pro-ed.
Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The communicative
effectiveness index: Development and psychometric evaluation of a functional communication measure for
adults aphasia. Journal of Speech and Hearing Disorders, 54, 113124.
McRae, K., Hare, E., & Ferretti, T. R. (2005). A basis for generating expectancies for verbs from nouns.
Memory and Cognition, 33(7), 11741184.
Moss Rehabilitation Research Institute. (2013). Philadelphia naming test (PNT). Retrieved from http://www.
mrri.org/philadelphia-naming-test
Nicholas, L. E., & Brookshire, R. H. (1993). A system for quantifying the informativeness and efficiency of the
connected speech of adults with aphasia. Journal of Speech and Hearing Research, 36, 338350.
Rogalski, Y., Edmonds, L. A., Daly, V. R., & Gardner, M. J. (2013). Attentive Reading and Constrained
Summarization (ARCS) discourse treatment for anomia in two women with moderate-severe Wernickes type
aphasia. Aphasiology, 27, 12321251.
Thompson, C. K. (2011). The Argument Structure Production Test/The Northwestern Assessment of Verbs and
Sentences. Northwestern University.
Webster, J., Franklin, S., & Howard, D. (2004). Investigating the sub-processes involved in the production of
thematic structure: An analysis of four people with aphasia. Aphasiology, 18, 4768.
86
1. Choose a variety of verbs that represent different types of actions. You can choose verbs together with
your participant. Just make sure you get a range of verbs.
Example: Chop, Kick, Deliver, Measure, Read, Erase, Watch, Fry, Stir, Sew
2. Avoid training verbs that are highly related or associated to avoid semantic interference.
Example: Chop/slice, Kick/throw, Stir/Shake
3. Generalization to (improvement of) untrained semantically related verbs (and nouns) is hypothesized
(and has been seen across VNeST studies), so you can evaluate potential improvement of related
verbs as generalization measures. The verb pairs and triads below are examples of semantically
related/associated verbs. The related word(s) are indicated by the arrow symbol ()) (so only one verb
in a pair/triad would need to be treated). This is not a comprehensive list of possibilities.
Example: ChopSlice, KickThrow, MeasureWeigh, ReadWrite, EraseScrub,
WatchExamine, FryBoilBake, StirShake, SewKnitCrochet, DeliverSend,
PushPull, PaintDraw
4. You can choose verbs that relate to a specific area of interest/functionality for the participant (e.g.,
cooking, sports), but it is recommended that you elicit a variety of scenarios about each verb beyond
the specific area of interest (to promote generalization). The example below shows how a verb like
watch and throw, which relate to activities surrounding a participants interest in a local football
team can be broadened to include more diverse language (Only Step 1 examples shown, not all
necessarily retrieved during one session).
VERB: Watch
Buckeye fan watch- football game/highlights
Coach watch tapes (from game)
Referees watch instant replay
Babysitter watch child/son/daughter
My wife and I watch sunset
Audience watch movie
VERB: Throw
Quarterback throw pass/hail Mary/football
Pitcher throw knuckle ball
Olympian throw javelin/shotput
Comedian throw pie
Baby throw tantrum
My son throw Frisbee (at beach)
5. Do not be afraid to try different verbs. In general, verbs should 1) require a subject and object and 2)
promote some diversity of responses (though verbs differ in this regard).
87
88
Abstract
Although the recovery course of severe aphasia is typically much lengthier and more
protracted than other forms of aphasia, availability of treatment time is often quite limited.
Focusing on one or more specific language domains, such as auditory comprehension, may
be indicated. When treatment time is limited, however, progress in an impairment-focused
approach may be insufficient to affect the individuals daily life. This paper provides a
process for selecting a daily activity, targeting that activity in a participation-focused
intervention, and measuring progress when treatment time is limited. Case examples
illustrate the process. A focus on even one activity that occurs daily can provide ongoing
opportunities for practice and interaction in spite of ongoing treatment.
Perhaps as many as 29% of individuals experiencing left hemisphere stroke and aphasia
experience severe or global aphasia, at least initially (Kang et al., 2010). Since aphasia can be
part of other medical diagnoses and diseases, it is not unusual for clinicians working in medical
settings to be faced with the challenge of selecting appropriate assessments and treatment for
someone with severe aphasia.
The course of severe aphasia can be much more protracted than the recovery patterns of
individuals with less severe aphasia. Published studies of individuals with severe aphasia suggest
that comprehension and repetition may improve the most during the first year after onset, but
that continuous improvement in all other language modalities including spoken language can
occur over many years (e.g., Bakheit, Shaw, Carrington, & Griffiths, 2007; Smania et al., 2010;
Stark & Pons, 2007). Other anecdotal reports suggest that the period of more rapid improvement
is also delayed, perhaps between 6 and 18 months, rather than during the first few months post
onset.
1
Content in this article was presented as part of a SIG 2 Invited Seminar at the ASHA
Convention, Chicago, 2013.
89
Assessment Score
90
Goals that map very clearly and specifically to the evaluation data are encouraged and
even required by most rehabilitation companies and facilities within their documentation systems
to facilitate reimbursement. Undeniably, the links between the initial evaluation data to the goal
and desired outcomes in Table 2 are straightforward, and because of their clarity and obvious
measurement, they are likely to be reimbursed.
Will these goals affect Mrs. Cs participation in life? Although initial performance on
impairment-focused assessments, like standardized aphasia batteries, may be related to activity
participation, change on impairment-based assessments is not necessarily related to change on
activity participation (Ross & Wertz, 1999, 2002). So, focusing our intervention on a specific
impairment, like impaired auditory comprehension, does not necessarily mean that the client will
now be equipped to participate in life activities.
If we want to increase the likelihood that we will facilitate life participation in our clients,
we have to assess current opportunities for improved participation and focus our intervention
efforts on those. Lets use Mrs. Cs performance on the Communication Activities of Daily Living
(CADL-2; Holland, Frattali, & Fromm, 1999) as an example. This assessment uses role play to
sample a number of activities that are likely to be relevant to a person with aphasia residing in
the community, such as shopping, going to a doctors appointment, ordering from a restaurant
menu, understanding a bus schedule, and filling out forms. The CADL-2 overall score for Mrs. C
was 17%. Since points on most items of the CADL-2 are given based on producing a fully
communicative message regardless of modality, her overall score tells us that Mrs. C is not able
to use many communication modalities very effectively to perform in these role-play activities.
We can analyze specific items within the CADL-2 that correspond to specific activities as
an informal way to track communicative performance. For example, we can analyze Mrs. Cs
ability to provide personal information such as name, address, and medical information with
items #36 of the CADL-2. Assuming that providing personal information is a valuable activity for
Mrs. C, then this can be targeted with a treatment goal. ASHA NOMS levels can be assigned
based on the likelihood that Mrs. C will use spoken language expression or writing to convey the
personal information. Possible goals derived from activities assessed on the CADL-2 are shown in
Table 3.
91
Providing personal Client will provide personal information using written information with
information, items #36 90% accuracy with minimal cues.
Using the phone, items Client will dial 911 and indicate emergency type with 90% accuracy given
4042, 44 minimal cues.
Shopping, items 3037 Client will identify written categories associated with shopping with 90%
accuracy with minimal cues.
Source. Adapted from Leach, E., Cornwell, P., Fleming, J., & Haines, T. (2010).
92
Abstract
Given the potential of long term intervention to positively influence speech/language and
psychosocial domains, a treatment protocol was developed at the Stroke Comeback Center
which addresses communication impairments arising from chronic aphasia. This article
presents the details of this program including the group purposes and principles, the use of
technology in groups, and the applicability of a group program across multiple treatment
settings.
In 2014, the stark reality of treatment for individuals with aphasia is that clinicians
are being asked to do more with less: less time and fewer dollars. This limitation in treatment
necessitates solutions that stretch dollars while providing efficacious treatment. As a result
aphasia communities are growing in popularity and in numbers (Simmons-Mackie & Holland,
2011). One such aphasia community is the Stroke Comeback Center in Vienna, VA founded to
provide long-term communication support operating within a Life Participation Approach to
Aphasia. Participants in this program are welcome to attend programs for as long as they feel they
are receiving benefit, which results in a community of stroke survivors dedicated to improving and
from whom much can be learned. This article shares information that has been learned through
involvement with over 300 participants at the center and which might reasonably be applied
across settings, including group purposes and principles and the use of technology that facilitates
improved communication.
100
Home & Community Cleaning the house, doing laundry, grocery shopping, going to the doctor,
Activities voting
Creative & Relaxing Using a computer, bird watching, drawing/painting, listening to music,
Activities going to the movies
Physical Activities Golfing, yoga, walking, swimming, fishing
Social Activities Family gatherings, eating out, picnic, storytelling, using the phone
94
Case Example
Mr. L was diagnosed with a global aphasia 2.5 months ago when he was hospitalized with
a left hemispheric stroke. During that time, he underwent inpatient rehabilitation that
culminated in his discharge to home with home health services. He has continued to make
physical improvements along with some small improvements in his communication. Because of
his physical improvements, he was referred to outpatient services for continued therapy.
At this particular outpatient facility, outpatient visits are encouraged to last for only
30 minutes, and are scheduled three times per week. It is anticipated that Mr. L will be able to
receive approximately one month of outpatient speech therapy based on his supplemental
insurance. So, a total of 12 sessions is anticipated.
Mr. L attends his first outpatient session with his wife, Mrs. L, with whom he lives. They are
both retired and prior to Mr. Ls stroke, enjoyed an active social life in their retirement community.
Determine the Clients Priorities
Knowing that there are as few as 12 sessions available for intervention, it is important to
incorporate the clients priorities as much as possible. During the LIV card sort, Mr. L selected
the restaurant picture as an important one. During the interview, Mrs. L stated that going out
with these friends was very important to them, and now her only time to go out socially.
Mr. and Mrs. L routinely go out to dinner two times a week with friends from church (one day
a week) and a group of neighbors (another day a week). Each group goes to different restaurants each
time, but there is a limited set of restaurants because of distance and group preferences
Mrs. L reported that, on the last few occasions when they went out to a restaurant, Mr. L
seemed to get very upset, pushing the menu away, and using obscenities when she tried to order
for him. She knows he is embarrassed or uncomfortable since he is unable to order for himself,
but she doesnt know how to handle the social situation.
Complete Formal and Informal Assessment
Language assessment data at the time of discharge from home health approximately
3 weeks prior to Mr. Ls first outpatient appointment is provided in Table 6. Although Mr. Ls ability
to match spoken or written words to pictures is relatively good, he still has substantial difficulty
understanding sentences. His expression is severely limited, and he is unable to name pictures.
95
Assessment Score
96
Goal #1 Client will request specific food items using speech, gesture, or writing in an
appropriate social context given minimal cues 80% of the time.
Goal #2 Client will use written choices to express basic personally relevant information
in conversation with familiar partners 80% of opportunities with minimal cues.
Goal #3 Client will request repetition using gesture as needed to improve auditory
comprehension in social interactions 80% of opportunities given minimal cues.
Goal #4 Client will request additional time to facilitate expression of personally relevant
information by using gesture 80% of opportunities given minimal cues.
Treatment Plan
Given the goals shown in Table 7, a few treatment approaches are viable options.
Beginning with the clients prioritized activity of ordering in a restaurant, using role play
as a means to practice successful strategies that will be realistic options within that particular
social context will be a good start (Hinckley & Carr, 2001, 2005). Menus from restaurants that
the client typically frequents with his wife can be downloaded or brought to the session and used
for a context-specific practice. The clinician should play the role of the wait staff, and coach the
client with the strategies that will work best for that client, including pointing to the items he
wants to order on the menu. This whole-task, context-specific practice should be completed at
each treatment session to achieve the desired level and to become long-lasting over time. The
critical elements of such an intervention are shown in Table 8. The clinician can also coach the
client to request repetition with a gesture to enhance auditory comprehension. A gesture that
indicates a request for more time should also be trained in the menu-ordering context. Finally, an
escape communication, perhaps a gesture, can be trained, with which the client can request
assistance from his wife.
Table 8. Critical elements of an activity-specific intervention (after Hinckley & Carr, 2005).
1. Establish compensatory strategies based on the participants strengths to achieve the task.
2. Use various means, including a variety of modalities, to achieve effective performance of the task.
3. Use problem-solving feedback interspersed within the targeted task.
4. Role-play the task.
5. Evaluation of performance should be based on communication adequacy and determined by the
listener receiving the message.
97
References
Bakheit, A. M. O., Shaw, S., Carrington, S., & Griffiths, S. (2007). The rate and extent of improvement with
therapy from the different types of aphasia in the first year after stroke. Clinical Rehabilitation, 21, 941949.
Haley, K. L., Womack, J., Helm-Estabrooks, N., Lovette, B., & Goff, R. (2012). Supporting autonomy for
people with aphasia: Use of the Life Interests and Values (LIV) Cards. Topics in Stroke Rehabilitation, 20(1),
2235.
Helm-Estabrooks, N., Ramsberger, G., Morgan, A. R., & Nicholas, M. (1989). Boston Assessment of Severe
Aphasia. Austin, TX: Pro-Ed.
Hilari, K., & Byng, S. (2009). Health-related quality of life in people with severe aphasia. International
Journal of Language and Communication Disorders, 44, 193205.
Hilari, K., Needle, J. J., & Harrison, K. L. (2012). What are the important factors in health-related quality of
life for people with aphasia? A systematic review. Archives of Physical Medicine & Rehabilitation, 93, S86S95.
98
110
Abstract
Given the potential of long term intervention to positively influence speech/language and
psychosocial domains, a treatment protocol was developed at the Stroke Comeback Center
which addresses communication impairments arising from chronic aphasia. This article
presents the details of this program including the group purposes and principles, the use of
technology in groups, and the applicability of a group program across multiple treatment
settings.
In 2014, the stark reality of treatment for individuals with aphasia is that clinicians
are being asked to do more with less: less time and fewer dollars. This limitation in treatment
necessitates solutions that stretch dollars while providing efficacious treatment. As a result
aphasia communities are growing in popularity and in numbers (Simmons-Mackie & Holland,
2011). One such aphasia community is the Stroke Comeback Center in Vienna, VA founded to
provide long-term communication support operating within a Life Participation Approach to
Aphasia. Participants in this program are welcome to attend programs for as long as they feel they
are receiving benefit, which results in a community of stroke survivors dedicated to improving and
from whom much can be learned. This article shares information that has been learned through
involvement with over 300 participants at the center and which might reasonably be applied
across settings, including group purposes and principles and the use of technology that facilitates
improved communication.
100
113
102
103
104
Acknowledgements
The author wishes to acknowledge professional colleagues Melissa S. Richman, M.S.,
CCC-SLP, Suzanne C. Redmond, M.S. CCC-SLP, and Brooke Hatfield, M.S., CCC-SLP for their
assistance in compiling the clinical information.
References
Bernstein-Ellis, E., & Elman, R. (1999). Aphasia group communication treatment: The Aphasia Center of
California approach. In R. Elman (Ed.), Group treatment of neurogenic communication disorders: The expert
clinicians approach (pp. 4756). Boston: Butterworth-Heinemann.
Centers for Medicare & Medicaid Services (n.d.). Medicare benefit policy manual. Chapter 15- Covered
medical and other health services. Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/downloads/bp102c15.pdf
deRuiter, J., Weston, G., & Lyon, S. M. (2011). Dunbars Numbers: Group Size and Brain Physiology in
Human Reexamined. American Anthropologist, 113(4), 557568.
GoQ Software (n.d.). Available from www.goqsoftware.com
Fridriksson, J., Hubbard, H. I., Hudspeth, S. G., Holland, A. L., Bonilha, L., Fromm, D., & Rorden, C. (2012)
Speech entrainment enables patients with Brocas aphasia to produce fluent speech, Brain, 135(12),
38153829.
Simmons-Mackie, S., & Holland, A. L. (2011). Aphasia Centers in North America: A survey. Seminars in
Speech and Language, 32(3), 203215.
Williamson, D. S. (2012, November). Treatment of Apraxia of Speech Using Static and Dynamic Modeling.
Seminar presented at the American Speech-Language-Hearing Association, Atlanta, GA.
Williamson, D. S., & Richman, M. S. (2007). Outcomes Within the International Classification of Functioning,
Disability and Health at a Community-Based Stroke Center. Paper presented at the American Speech-
Language-Hearing Association Convention, Boston, MA.
105
Darla Hagge
Department of Speech Language Pathology, California State University Sacramento
Sacramento, CA
Financial Disclosure: Candace Vickers is Program Director of Speech-Language Pathology at
California Baptist University. Darla Hagge is an Assistant Professor at California State University
Sacramento.
Nonfinancial Disclosure: Candace Vickers has previously published in the subject area. Darla
Hagge has previously published in the subject area.
Abstract
This article describes Communication Recovery Groups (CRG), an aphasia group program
that is sponsored by a medical setting and more recently a university setting. CRGs history
and approach and its model of service in light of current healthcare challenges are summarized.
The article also provides a detailed discussion regarding the logistics of offering conversation
groups to persons with aphasia which are sponsored by medical and/or university settings,
the intake process for new group members, and the training of student volunteers to help
lead conversation groups.
According to figures from the American Medical Association (2007) there are over one million
Americans living with aphasia each year. These sobering figures coincide with current challenges
in healthcare for outpatient rehabilitation clinicians providing services under the Medicare Cap
(Centers for Medicare and Medicaid Services, 2014). When formal therapy for aphasia ends,
persons with aphasia (PWA) may experience a void in terms of the chance to experience satisfying
and supportive communication in meaningful interactions with others. Below, we describe several
factors which highlight the critical need for more availability of aphasia friendly communication
programming for persons with chronic aphasia after discharge from formal therapy.
While Elman and Bernstein-Ellis (1999) report strong evidence that group communication
treatment is efficacious and there has been some growth in numbers of groups for PWA over the
last decade nationwide, options for ongoing assistance with aphasia after discharge from traditional
therapy remain limited. Simmons-Mackie and Holland (2011) report there are only 26 aphasia
centers in North America. The National Aphasia Association (NAA, 2011) lists 13 intensive aphasia
programs in North America and more than 200 aphasia-related groups in North America. Some
groups are designed for the PWA and others for partners, but not all groups meet weekly.
In addition, Hilari and Northcott report reduced social networks (2006) and loss of friendships
for PWA (Northcott & Hilari, 2011) in the United Kingdom after aphasia. In the United States, there
is evidence that after the onset of aphasia, social network size and amount of regular contact with
communication partners reduce by approximately 50% from pre-aphasia levels (Vickers, 2010).
This social isolation combined with a lack of available aphasia programming at the community
level in many areas of the United States perpetuates the loneliness and frustration for many with
aphasia (Vickers & Hagge, 2013).
As a response to the lack of opportunities for PWA in the Southern California area, in 1994
Vickers launched the first hospital based Communication Recovery Group (CRG) using trained
106
108
109
110
Conclusion
Since October of 2013, outpatient rehabilitation centers have felt the impact of the Medicare
Cap very keenly. The impact of the Cap and managed care, along with the aging of the population
and rate of aphasia in the United States, make programs like CRG even more important for PWA
after discharge from formal services. It is possible to replicate the CRG model of groups using trained
volunteers in other places to provide a needed outlet for PWA to find meaningful communication
and social connection which may enhance their quality of life.
In the medical setting, we often add complimentary sessions of CRG-Fullerton to an
individuals weekly program as part of his/her discharge planning. CRG-Fullerton supports the
often delicate transition from outpatient services to community re-entry, and often serves to
encourage individuals as they meet other PWA have travelled further down the road of improvement.
The additional social network of friends which develops also appears to aid recovery. In the university
111
References
Albrecht, G. L., Seelman, K. D., & Bury, M. (2001). Handbook of Disability Studies. Thousand Oaks, CA:
Sage Publications, Inc.
American Medical Association. (2007). From the Centers for Disease Control and Prevention: Prevalence of
Stroke -United States, 2005. Journal of the American Medical Association, 298(3), 279281.
American Speech Language Hearing Association. (2007). Scope of Practice in Speech-Language Pathology
[Scope of Practice]. Available from www.asha.org/policy
Aphasia Institute (n.d.a.). DVD: Supported Conversation for Adults with Aphasia. Retrieved from http://www.
aphasia.ca/shop/dvd-supported-conversation-for-adults-with-aphasia/
Bernstein-Ellis, E., & Elman, R. (1999). Aphasia group communication treatment: The Aphasia Center of
California approach. In R. Elman (Ed.) Group treatment of neurogenic communication disorders: The expert
clinicians approach (pp. 4756). Boston: Butterworth-Heinemann.
California State University Sacramento (CSUS; n.d.a.). Graduation Initiative Strategic Plan. Retrieved from
http://saweb.csus.edu/students/download/GraduationInitiativeReportOctober21.pdf
Centers for Disease Control and Prevention. (2013). Healthy Communities Program. Retrieved from http://
www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/
Centers for Medicare & Medicaid Services. (2014). Therapy Cap. Retrieved from http://www.cms.gov/
Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/
Medical-Review/TherapyCap.html
Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, Lyon, J., & Simmons-Mackie, N. (2000). Life
participation approach to aphasia: A statement of values for the future. ASHA Leader, 5(3), 46.
Commission on Accreditation of Rehabilitation Facilities (CARF; 2012). CARF: Accreditation Focuses on
Quality, Results. Retrieved from www.carf.org/home/
Elman, R. (2011). Starting an aphasia center? Seminars in Speech and Language, 32, 268272.
Elman, R., & Bernstein-Ellis, E. (1999). The efficacy of group communication treatment in adults with
chronic aphasia, Journal of Speech and Hearing Research, 42(2), 411419.
Garrett, K. L., & Beukelman, D. R. (1992). Augmentative communication approaches for persons with severe
aphasia. In K. Yorkston (Ed.) Augmentative communication in the medical setting (pp. 245338). Tucson, AZ:
Communication Skill Builders.
Glista, S., & Pollens, R. (2007). Educating clinicians for meaningful, relevant and purposeful aphasia group
therapy. Topics in Language Disorders, 27(1), 351371.
Hagge, D., Heard, M., Williams, L., & Vickers, C. (2014). Training aphasia group student volunteers: Virtual
file access and storage. Poster presentation for the California Speech-Language-Hearing Association, March
2014, San Francisco, CA.
Hilari, K., & Northcott, S. (2006). Social support in people with chronic aphasia. Aphasiology, 20(1), 1736.
Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001) Training volunteers as
conversation partners using Supported conversation for adults with aphasia (SCA): A controlled trial,
Journal of Speech, Language and Hearing Research, 44, 624638.
Kaplan, D. (2000). The definition of disability: Perspective of the disability community. Journal of Health
Care Law and Policy, 3(2), 352364.
Klein, K. (1996). Coping With the End of Third-Party Reimbursement for Individual Speech-Language
Pathology Services. National Aphasia Association Newsletter, 8, 2. Retrieved from http://www.aphasia.org/
article-naacoping.php
Lee, S., Funes, B., Vickers, C., & Hagge, D. (2013). Technology and aphasia groups: Enhancing participation.
A poster session presented at the American Speech-Language-Hearing Association, November, 2013,
Chicago, IL.
112
113
Abstract
Providing education and partner training for the primary communication partners of
persons with aphasia is often challenging for medical-based speech-language pathologists
(SLPs). Todays healthcare environment is fraught with barriers to obtaining services for
individuals with aphasia and their significant others. This article describes a proposed
alternative service delivery model for the partners of persons with aphasia.
Aphasia impacts the communication of a person with aphasia (PWA) but its presence may
also negatively affect the significant other (SO) of the PWA, including permanent life changes and
health-related issues such as depression or anxiety. The World Health Organization (WHO, 2001)
refers to this phenomenon as a third-party disability and calls for continued research in this
area. This line of inquiry is imperative because the supporting SO may be the most critical person
in the PWAs life (Threats, 2010).
114
115
Conclusion
Clearly, healthcare and the traditional service delivery model will continue to evolve and
change over time. It is likely that alternative service delivery models will become an integral
vehicle for speech-language pathology services. A group-based communication training series for
the partners of PWA may offer a viable option for partner education and training. In addition to
the core training curriculum, a group program may provide partners with peer support and
learning, as well as supporting the coordination of care including referrals.
116
117