Aphasia Treatment Approaches and Protocols: Step-by-Step Guides with Examples

In this post, you’ll find step-by-step Aphasia protocols that spell out exactly what to do. You’ll also find summaries of the broader Aphasia “approaches.”

For each treatment, we link to other helpful resources, including printable PDFs, apps, videos, and journal articles.

Aphasia Pack PDF Patient Handouts Worksheets Resources image 0

Aphasia Handouts, Worksheets, and therapist treatment guides.

Aphasia Treatments We’ll Cover

NAMING

  1. VNeST (Verb Network Strengthening Treatment)
  2. Intention Manipulation
  3. Semantic Feature Analysis
  4. Phonological Component Analysis (PCA)

REPETITION

  1. Melodic Intonation Therapy
  2. [Intention Manipulation]

FLUENCY

  1. Scripted Conversation
  2. Sentence Production Program for Aphasia (SPPA)
  3. [Melodic Intonation Therapy]

SYNTAX PRODUCTION

  1. Response Elaboration Training
  2. Treatment of Underlying Forms
  3. [Sentence Production Program for Aphasia (SPPA)]

AUDITORY COMPREHENSION

  1. Schuell’s Stimulation Approach

REDUCE RESPONSE LENGTH

  1. Promoting Aphasic’s Communication Effectiveness (PACE)
  2. Augmented Input

REDUCING CIRCUMLOCUTIONS

  1. [Phonological Component Analysis (PCA)]

OTHER TECHNIQUES

  1. Supported Conversation for Adults with Aphasia (SCA)

    * MORE RESOURCES

Naming

1) VNeST (Verb Network Strengthening Treatment)

What’s the goal?

To improve expressive language.

The goal of VNeST is to improve word-finding and build sentences.

How Does it Work?

The therapist presents a verb. The patient then builds a sentence from this verb, filling in the WHO and WHAT. We use the terms agent for the WHO and patient for the WHAT.

A simple English sentence is structured: WHO (agent) DID (verb) WHAT (patient).

For example: JINAE (agent/WHO) THREW (verb/DID) THE BALL (patient/WHAT).

Preparation:

A free printable agent/patient pair list is linked below.

1. (10 notecards) Choose 10 familiar verbs (e.g., measure, watch). Write each verb on a notecard.

Your verbs should:

1) Take an object (“arrive” won’t work)
2) Be familiar but not too broad (“is” and “have” are too broad)
3) Be different from each other (don’t choose both “throw” and “toss”).

2. (60 notecards) Choose 3 agent/patient pairs for each verb (e.g. for the verb “measure,” you choose carpenter/wood and designer/dress). Write each agent and patient on separate notecards.

3. Your patient may say a different agent/patient pair than the ones you
chose. Have blank notecards ready to write these down. The patient-generated agent/patient pair will replace one of the 3 agent/patients you chose.

4. (5 notecards) Write WHO, WHAT, WHERE, WHEN, and WHY on separate notecards.

5. You should have written on a total of 75 notecards (and have a stack of blank notecards handy).

Basic Treatment:

1. Place down the WHO, WHAT, and one VERB card.

2.Ask the patient, “WHO can VERB?” and “WHAT can BE VERBED?” For example, “WHO can MEASURE?” and “WHAT can BE MEASURED?”

3. The patient must produce a 3+ word sentence in response to your questions. For example, “Carpenter measures wood” is a correct response.

IF CORRECT:

What’s a Correct Answer?

Agent/patient pairs should be specific.

For example, don’t accept “the man fixes the car” or “the person watches the cartoon.” Instead, ask the patient to think of words that tend to go together like “mechanic/car” and “child/cartoon.”

4. Once the patient gives a correct answer, place down the corresponding agent and patient cards—or write the words down on blank notecards if they choose words you didn’t prepare.

5. Using the same verb card, ask “WHO else can VERB?” and “What else can BE VERBED?” Place down the corresponding cards (or write on new cards) as the patient answers.
• For example, “Who else can measure?” and “What else can be measured?”

6. Continue until all 3 agent/patient pairs for the verb is used (or your patient has
named 3 agent/patient pairs on their own).

7. Remove the verb card and 3 agent/patient pairs.

8. Replace with a new verb and begin again.

IF INCORRECT:

4. If the patient can’t produce a correct 3+ word sentence, then place 1 correct word and 3 foils on the table (4 notecards).

5. The patient will identify the correct word, then read it aloud. Provides cues as needed.

6. Remove all of the foils and continue with treatment.

Going Deeper, Part 1:

1. Have the patient choose one of the agent/patient pairs (such as “carpenter” and “wood”).

2. Ask WHERE, WHEN, and WHY questions about the pair
• Short phrases are fine—complete sentences aren’t required (see example below).

3. Write the patient’s responses on blank notecards. Place them next to the appropriate cards (see image below).


Going Deeper, Part 2:

1. Remove all cards from the table.

2. Prepare 12 sentences containing a target VERB (“measure”):
– 3 sentences will be correct
– 3 sentences will have the inappropriate agent
– 3 sentences will have the inappropriate patient
– 3 sentences will have the agent and patient switched.

What?

Inappropriate agent: The dentist measures wood. The policeman measures
chemicals. The farmer measures clothes.

Inappropriate 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.

3. Read the sentences, one at a time. Ask the patient to identify whether each sentence makes sense or not.

4. Finally, using the same target verb, ask the original questions: “WHO can VERB” and
WHAT can be VERBEDWITHOUT setting down any cards.

Medical SLP Reference Chart Instant Download Adult Speech image 0

Medical Speech Therapy Reference Chart: Seven printable, full-color pages.

V-NeST Resources:

1. FREE agent/pair pair list (PDF):

2. Lecture by Dr. Edmonds: (VNeST) on Lexical Retrieval of Content Words in Sentences in Individuals with Aphasia.

3. Advanced Naming Therapy App by Tactus Therapy.

Article:
1. Effect of Verb Network Strengthening Treatment (VNeST) on Lexical Retrieval of Content Words in Sentences in Persons with Aphasia

2) Intention Manipulation

What’s the goal?

To improve expression language.

Intention Manipulation is a treatment approach that aims to recruit the right-hemisphere of the brain for patients with nonfluent aphasia. Research does suggest that this approach helps shift lateralization of language production to the right brain structures.

During intention manipulation, the patient completes a complex left-hand movement during a naming task.

How to:

1. The patient completes a complex left-hand movement. For example, they open the lid of a box then squeeze a rubber ball.

2. After the hand movement, ask them to name a target picture.

3. If correct, proceed to the next target picture.
• If incorrect, the patient: repeats the target word then completes a different left-hand movement (e.g. making a circle with his left hand).

Intention Manipulation Resources:

Articles:
An Intention Manipulation to Change Lateralization of Word Production in Nonfluent Aphasia: Current Status


3) Semantic Feature Analysis

What’s the goal?

To improve expressive language.

Semantic Feature Analysis helps a patient find a word (name a picture) by describing semantic features of the word.

These features are: what group it’s part of, what action it does, an associated word, properties of the word, where it’s located, and how to use it.

How To:

The therapist uses a worksheet (or “word web”). The target picture is usually placed in the center of the web.


1. Have a set of target pictures handy. We suggest 40, separated into groups of 10.

2. Prepare a blank word web (template below).

3. Introduce your patient to the word web.

4. Ask them to name the picture. Whether or not they can name the picture, encourage them to generate ALL of the following semantic features:

Semantic Features

Association. What does it remind you of?
Group. What type of thing is it?
Action. What does it do?
Properties. What does it look/taste/sound/feel like? (color, shape, size, etc)
Location. Where do you find it?
Use. What is it used for?

5. Write down their responses on the word web. Provide cueing as needed.

6. Again, ask the patient to name the picture. Summarize the web to prompt a correct answer: “It’s a vehicle that floats on water and is used for fishing.”

7. Use one set of 10 pictures per session, and rotate through the sets until the patient achieves 80% accuracy independently for each set.

Semantic Feature Analysis Resources:

1. Word Web Templates in English and Spanish (from RecipeSLP. Click for templates):

Spanish

2. Naming Therapy App by Tactus Therapy

Articles
1.
Semantic Feature Analysis Treatment for Aphasic Word Retrieval Impairments: What’s in a Name?

2. How to: Semantic Feature Analysis (SFA) for Anomia


4) Phonological Component Analysis (PCA)

What’s the Goal?

To improve expressive language.

PCA helps patients find a word (name a picture) by describing phonological features of the word.

Sound familiar? PCA is modeled after Semantic Feature Analysis. It uses a word web to help patients think of five phonological components of a target picture. These components are: first sound, another word that starts with that first sound, final sound, number of syllables, and rhyming word.

How To:

1. Have a set of target pictures handy. We suggest 40, separated into groups of 10.

2. Prepare a blank word web (see template below).

3. Introduce your patient to the word web.

4. Ask them to name the picture. Whether or not they can name the picture, encourage them to generate ALL of the following phonological features:

Phonological Features:

First Sound. What’s the first sound?
Another Word. What’s another word that starts with that sound?
Last Sound. What’s the last sound?
Number of Syllables. How many syllables does this word have?
Rhyming Word. What does it rhyme with?

5. Write down their responses on the word web, providing cueing as needed.

6. Again, ask the patient to name the picture. Summarize the web to prompt a correct answer: “Starts with ‘s’ and ends with ‘e’ or ‘y’, rhymes with ‘kitty’.”

7. 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:

Articles:
1. Therapy-Induced Neuroplasticity in Chronic Aphasia After Phonological Component Analysis: A Matter of Intensity

2. Treating naming impairments in aphasia: Findings from a phonological components analysis treatment.

Repetition

1. Melodic Intonation Therapy (MIT)

What’s the Goal?

To improve expressive language.

For over a century, therapists have observed that some people with aphasia can sing words that they can’t speak. MIT was developed based on this observation. Use MIT to lead 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

According to a study by Helms-Estabrooks, Nicolas, and Morgan (link below), the best candidates for improved expression language after MIT treatment are patients with:

  • a unilateral, left-hemisphere stroke
  • poorly articulated, nonfluent, or severely restricted speech output
  • able 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

Treatment Hierarchy

  1. Write down a word or phrase.
  2. Hum the word or phrase (use a higher-pitched note on the stressed syllable or word).
    Tap the patient’s left hand once on each syllable as you hum.
  3. Sing the word or phrase (again, use a higher-pitched note on the stressed syllable or
    word) and tap the patient’s left hand.
  4. Sing the word or phrase together with the patient, in unison, while continuing to tap each syllable.
  5. Continue to sing the word or phrase together while the patient taps with
    their left hand. Gradually fade your singing and tapping.
    • At this point, only provide hand tapping (no verbal or phonemic placement cues).
  6. Sing and tap while the patient listens. Next, ask the patient to sing and tap the word or phrase (you tap her hand without singing along).
  7. Immediately after the patient repeats the target word or phrase, ask “what did you say?” They should respond by singing and tapping the target word.
  8. Complete steps 1-7 with a new word or phrase.

MIT Resources:

From MEDRhythms

Articles
1.
Melodic Intonation Therapy: Shared Insights on How it is Done and Why it Might Help

2. Melodic intonation therapy: back to basics for future research

2) Intention Manipulation

Described above.


Fluency

1) Scripted Conversation

What’s the Goal?

To improve expressive language.

With this approach, the therapist helps a patient create scripts that will improve conversations in their daily life. An example is a script to order pizza over the phone.

See the link below for Rehabilitation Institute of Chicago’s template of scripts. Each has 5 levels of difficulty based on aphasia severity.

How to:

1. Work with your patient to create 3 scripts that would improve their daily conversations. Each should be useful for your patient and the right level of difficulty.

2. Include lines for both your patient and the conversation partner. For example, if the scrip is for paying a credit card bill over the phone, write lines for both the patient and the customer service agent.

3. The script should have 10 turns.

4. During their turn, the patient will respond to what the conversation partner just said.

Increasing Difficulty:

• Increase word and sentence length. For example, “I want to pay my bill,” can be replaced with “I’m calling to pay my September cell phone bill.”

• Increase semantic difficulty. For example, the word “help” can be replaced with “support,” “guidance,” or “assistance.”

Scripted Conversation Resources:

Script Templates (Rehabilitation Institute of Chicago)

Articles:
Script Templates: A Practical Approach to Script Training in Aphasia


2) Sentence Production Program for Aphasia (SPPA)

What’s the Goal?

To improve expressive language.

SPPA is sold by PRO-ED. It uses story completion tasks to elicit target sentences from a patient.

How to:

* SPAA is sold online, so will only be briefly described.

• Using picture cards that show action scenes, ask the patient to repeat a set of sentences that uses the 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:
• Read a story that contains the target sentence.

An example story: 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?” What does Andy ask the employee? The answer is “How much does the shirt cost?”

Level B:
• “When Andy doesn’t know the shirt’s price, what does Andy ask?”
• Next, ask the patient to use the same sentence structure (e.g. “How much does the shirt
cost?”) to complete different narratives.

SPPA Resources:

SPPA PRO-ED Purchase Page

Articles:
Sentence production in rehabilitation of agrammatism: A case study.

3) Melodic Intonation Therapy

Described above.


Syntax Production

1) Response Elaboration Training (RET)

What’s the Goal?

To improve expressive language.

The goal of RET is to increase the number of content-words patients with aphasia say during a conversation. Content words are nouns, pronouns, main verbs, adjectives, adverbs, and prepositions.

Unlike other aphasia treatment approaches, RET allows the therapist to follow the patient’s lead—instead of adhering to a strict set of rules.

For example, a therapist may say, “Tell me about this picture,” and ask questions based on the patient’s answer. There are no wrong answers, and the therapist encourages longer utterances with shaping, modeling, and chaining.

How to:

• Use RET with either visual or auditory prompts. When using an image, choose a simple picture (not abstract) that’s not too busy. This can help the patient elaborate on one theme.

Visual Prompt:
1. Show the patient a picture and say, “Tell me about this picture.” Let’s say it’s an image of a man brushing his teeth. The patient responds “Man…brushing.”

2. Reenforce the patient, then model and shape their response. “That’s right, he’s brushing his teeth.”

3. Ask questions to further elaborate their response. “What is he using to brush his teeth?” Then model and shape these responses, asking the patient to repeat your model. “Yes, he’s brushing his teeth with a toothbrush. Can you repeat that whole sentence?”

4. Continue this process of chaining to increase the number of content words.


Auditory Prompt:

Let’s use the example of a patient ready to advance to longer sentences and even multiple sentences.

1. Say, “Tell me in detail how to…” Complete the sentence with a functional task, like “pump gas” or “make a pot of coffee.”
• For example, “Tell me in detail how to brush your teeth.” The patient responds, “I grab my toothbrush, put on toothpaste, and brush my teeth.”

2. To elicit a more complex response, you say, “That’s right. Now let’s go into more detail. Pretend that I’ve never brushed my teeth before, so I need to hear how to do it step-by-step.”
• The patient then responds, “First, I grab my toothbrush and hold it under the running water. Then I put a small amount of toothpaste on my toothbrush and put the toothbrush in my mouth. I brush all of the parts of my teeth.”

3. Give the patient the time they need to fully respond. At 15 seconds of silence, ask, “Is there anything else?”

Response Elaboration Training Resources:

Articles:
1. A Qualitative Analysis of Response Elaboration Training Effects

2. Response Elaboration Training for Patient Initiated Utterances

2) Treatment of Underlying Form (TUF)

What’s the Goal?

To improve expressive language.

TUF was created to treat agrammatic aphasia. The goal is to increase syntactic complexity. It is rooted in formal linguistic theory and in psycholinguistic and neurolinguistic research.

Using action pictures and notecards, the therapist helps their patient build sentences.

Preparation:

1. Find 10 pairs of action scene pictures that have both a subject and an object:

• Something is doing an action, while something else receives that same action.
• One picture will show the target sentence and the other will show its semantically reversed counterpart. For example, one picture is of a girl kissing a boy (target sentence), and the other picture is a boy kissing a girl (semantically reversed counterpart).

2. (20 Notecards) For each of the 10 pictures, write the subject and object on separate notecards.

3. (10 Notecards) On separate notecards, write the 10 verbs that describe the action in each picture. For example, the word “petting” for the picture of a boy petting a cat.


4. (8 Notecards) Write each of the following words/symbols on separate notecards:

WHO
WHAT
?
IT
WAS
BY
SEEMS
TO HAVE

Treatment:

TUF has four different treatment protocols (depending on what kind of sentence you want your patient to produce).

We’ll cover one of these protocols, the Object-extracted wh-questions (wh-movement).

From Thompson, C. (2001). Treatment of Underlying Forms: A linguistic Specific Approach for Sentence Production Deficits in Agrammatic Aphasia. In R. Chapey (Editor). Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders (4th edition, pp. 605-628). Lippincott Williams & Wilkins.

1. Present a pair of pictures, one showing the target sentence and the other showing its semantically reversed counterpart (e.g. “girl kissing boy” is target and “boy kissing girl” is reversed).

2. Model the target sentence type (in this case, object-extracted wh-questions) using the semantically revered picture. Then, ask the patient to produce a similar sentence using the target picture. You say, “the boy is kissing the girl,” then you point to the target picture and ask to produce a similar sentence.

• If a grammatically correct wh-question is produced, present a new pair of pictures.
• If incorrect, complete the following steps using the picture of the semantically reversed pair (boy kissing girl).

3. Place down a notecard with the subject, object, and action, along WHO, WHAT and ?

• For example: THE BOY (subject notecard), IS, KISSING (action notecards), THE GIRL (object notecard) is placed in the correct order. Place the WHO, WHAT, ? notecards above the sentence.

• Point to the verb and say “this is KISSING, it is the action of the sentence”
• Point to the subject and say “this is THE BOY, he is the person doing the kissing”
• Point to the object and say “this is THE GIRL, she is the person being kissed”

4. Replace the object with either WHO (or WHAT, whatever is appropriate).

• Say “the person 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, ?

5. Inverse the subject and auxilitary verb by placing IS at the beginning of the sentence.
IS, THE BOY, KISSING, WHO, ?

6. Move the wh-morpheme to the sentence initial position. Ask the patient to read (or repeat) the resultant question.

WHO, IS, THE, BOY, KISSING, ?

7. Re-arrange the word cards to make a declarative sentence again, just like in step 3 (the girl is now the subject and the boy is the object, so the notecard positions will be switched for the target sentence).

Remove the semantically reversed picture and place down the target picture (e.g. girl kissing boy).

Now ask the patient to move the cards to form a question. They complete steps 4-6, and you provide assistance as needed.

8. Back to step 1 with a new pair of action pictures.

TUF Resources:

Article
Treatment of Underlying Forms in a discourse context

Book
From Thompson, C. (2001). Treatment of Underlying Forms: A linguistic Specific Approach for Sentence Production Deficits in Agrammatic Aphasia. In R. Chapey (Editor). Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders (4th edition, pp. 605-628). Lippincott Williams & Wilkins.

3) Sentence Production Program for Aphasia (SPPA)

Described above.


Auditory Comprehension


1. Schuell’s Stimulation Approach

What’s the Goal?

To improve receptive and expressive language.

As the name suggests, Schuell’s Stimulation Approach is an “approach” to aphasia treatment—not a protocol. Its goal is to reorganize language that was disrupted by brain damage through the use of sensory stimulation.

This approach emphasizes therapist flexibility, a clear understanding of the patient’s strengths and weaknesses, and treatment that’s meaningful to the patient.

Use Schuell’s Stimulation Approach with:

Receptive and/or Expressive Language Tasks. We put together treatment tasks for you!

How to:

Present the patient with strong, controlled, and intensive auditory and sensory stimulation.

Principles of treatment:

• Use the right level of sensory stimulation for each patient.
• 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, provide more stimulus (not correction or instruction).
• A maximum number of responses should be elicited (you should have lots of responses since you’re giving lots of stimuli).
• Give reinforcement and feedback about accuracy. Read your patient to determine how much feedback is best to motivate and encourage.
• Have a plan of action. Treatment should be systematic and intensive.
• Start with familiar and relatively easy tasks. Let patients “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 be extensions of familiar materials and procedures. This way, the patient’s focus is on language processing—not on conforming to new content.

Which Stimulus Work?

Below is a looooong list of specific stimuli that can improve aphasia treatment. It was compiled by Coelho, Sinotte, and Duffy (link below).

Reduce background noise
• Patients name realistically colored images better than line drawings
• The image should be as unambiguous as possible. If ambiguous, considering pairing it with an object that sheds light on the function of the object. For example, pair the target word “mug” with a coffee pot. But make sure the paired object doesn’t make the object even more ambiguous.
‘Operative’ objects are easier to name. A rock is operative. Operative objects are distinct, have multiple recognizable forms, and are firm to the touch.
• Objects that conjure the senses are also easier to name (a rock feels rough, looks brown, is dense, etc)
• Patients prefer large print, even those without visual/visual processing deficits.
• Patients prefer to be spoken to face-to-face over listening to the same information through headphones (or to watching a recording).
• It’s harder for patients to accurately name pictures that are semantically similar. For example, a chair, table, and a stool.
• Patients more easily confuse words that are phonetically similar (horse vs house) or visually similar (E vs F).
• An image with few alternative responses leads to more accurate naming. For example, the image of a shoe has fewer alternative responses than the image of a landscape.
• When evaluating an auditory comprehension deficit, picture verification tasks (asking “Is this a fork?” while presenting a picture of a knife) are more sensitive than ‘point to tasks (“Point to the knife” while presenting four images).
• Combining multiple types of sensory stimulation can 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.
Constraint-induced language treatment: Massed practice of language skills, while other forms of communication are constrained (e.g., gestures, compensatory strategies such as circumlocution.)
•There’s some evidence of improved language comprehension when therapists speak slower and add pauses.
Shorter auditory messages improve comprehension and retention; single words are easier to understand than phrases or sentences. When reading, shorter words (one syllable and less than 4-5 letters) are easier to comprehend.
• Sentences and paragraphs are easier to comprehend when they’re redundant.
• Cater cues and prompts to your patient; take the time to understand where your patient’s language breaks down (semantic level? Phonological level?) Take note of what cues work and don’t work for each patient.
Multisensory, graded cues and prompts can be very effective. Beyond auditory and visual, prompts can include letter tracing, writing words, and gestures. Grading cues can progress from maximal to minimal cues (word repetition graded down to asking what the object’s function is) or visa-versa.
Semantic cues improve naming accuracy (“This is something you wear on your head,” for hat). See Semantic Feature Analysis described above.
•Phonological cues also 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.
• Keep in mind that word frequency is individual. Consider whether the word or phrase is actually common for your patient, given their culture and life experiences.
• Abstract words are harder.
• When working on word retrieval and naming, consider varying parts of speech and semantic categories (beyond only naming objects).
• To increase sentence comprehension, consider syntax and grammar. See Treatment of Underlying Form described above.
Add context to improve comprehension. Main ideas are easier than details. Someone talking naturally is easier to understand than “correct” communication. Patients tend to remember scripts from their own life (ordering at a restaurant).
• Patients respond more quickly to stressed words. See Melodic Intonation Therapy described above.
Progress from easiest tasks to hardest tasks to build up successes.
• As a therapist, do your best to be patient and present. Patients pick up on negative emotional cues, even subtle ones. Give lots of opportunities for success.
• Respect signs of fatigue and encourage plenty of rest and breaks. Try to schedule therapy when your patients aren’t as tired (e.g., not right after PT or before bedtime)
Be aware of potential auditory deficits and how each impact language

Example of Schuell’s Stimulation Approach in Treatment:

Mr. Gupta has severe Wernicke’s aphasia. The majority of his expressive language is jargon. He answers yes/no questions presented auditorily at 50% accuracy and follows 1- step commands at 40% accuracy. You decide to use Schuell’s Stimulation Approach to increase auditory comprehension.

You set a goal for increasing yes/no question accuracy to 80%. First, you ask a yes/no question aloud. Mr. Gupta doesn’t respond, so you ask the question again using a more sing-songy voice and speaking slower. Mr. Gupta appears to understand that he is being asked a question. You ask the question again, using a sing-songy voice, slow speech, and gestures (e.g. shrugging, nodding, shaking your head, etc.). This elicits a verbal response from Mr. Gupta, though he answers incorrectly. You provide feedback by asking the question again and using a sing-songy voice, slow speech, and gestures to indicate the correct response.

You set a goal for increasing two-word phrase repetition to 80%. You ask Mr. Gupta to repeat a phrase. He appears confused, so you ask him to repeat the phrase while speaking louder, slower, and pointing to your mouth. He then repeats only the second word. You tell him, “Good try,” and repeat the phrase again, using exaggerated mouth movements when saying the word he missed. He then repeats the entire phrase, and you provide verbal and visual feedback by saying, “Correct!” while giving him a thumbs up and a smile.

Schuell’s Stimulation Approach Resources:

Schuell’s Stimulation Approach to Rehabilitation (chapter)

Reducing Response Length

1) Promoting Aphasic’s Communication Effectiveness (PACE)

What’s the Goal?

To improve expressive language.

PACE therapy uses conversation to improve communication. The patient first chooses a form of communication (talking, gestures, writing, AAC devices, Pictionary, etc). The therapist and patient then take turns conveying messages. The therapist gives cues and feedback and can even score how successfully the message was communicated (see below for scoring scale).

How to:

• Emphasize practical messages that matter to the patient. For example, their name, phone number, or ordering at a favorite restaurant.
• Let patients choose the form of communication (e.g., speech, gestures).
• The therapist and patient take equal turns sending and receiving messages. For example, you say, “What would you like to order?” Now it’s the patient’s turn to respond.
• Give feedback about how clearly the patient conveyed their message. Use errorless learning and spaced retrieval to increase accuracy.
• Train the primary caregiver to take turns sending and receiving messages then providing feedback to the patient.

Rating Scale to Score Message-Clarity (From Nova Scotia Hearing and Speech Centres)

• 5. Message conveyed on first attempt
• 4. Message conveyed after general feedback from the clinician
• 3. Message conveyed after specific feedback from the clinician
• 2. Message partially conveyed
• 1. Message not conveyed
• 0. No attempt to convey message

2) Augmented Input

What’s the Goal?

To improve receptive language.

To improve comprehension, the communication partner ‘augments’ or adds visual input to spoken language.

How to:

The added visual input can be intermittent or continuous. Pause periodically to check comprehension. Augmented input can include:

• Written key-words: the main topic, topic changes, key ideas,
questions, response choices, etc.
• Gestures (pointing, symbolic gestures, pantomime)
• Graphics (maps, pictures)
• Physical objects
• Other writing or drawing while communicating


Reducing Circumlocutions


1. Phonological Component Analysis

Described above.


Other Techniques

1. Supported Conversation for Adults with Aphasia (SCA)

What’s the Goal?

To improve receptive and expressive language.

SCA was developed by the Aphasia Institute to “help people with aphasia re-join life’s conversations.” The goals of this approach are to 1) acknowledge the competence of the person with aphasia and 2) help them reveal their competence.

Treatment focuses on the communication partner, not the patient.

How to Acknowledge Competence:

  • Use a natural tone of voice
  • Choose adult/complex topics of conversation
  • Express that you know that the patient knows more than they can communicate
  • Attribute communication breakdowns to your own limitations as a communicator
  • Be open when you have to turn to someone else to get information

How to Reveal Competence:

  • Use short, simple sentences and visual information, such as gestures, written keywords, and pictures.
  • Reduce distractions
  • Observing their non-verbal social cues to help understand their level of comprehension.
  • Summarize what you believe the message to be and ask for clarification.
  • Ask yes/no questions.
  • Ask one question at a time.
  • Ask specific questions: For example, “For lunch, I can make a sandwich or soup. Which one do you want?” (versus “What do you want for lunch?” which is too general)
  • Request more information by asking the patient to gesture, point, write, etc.
  • Give the patient plenty of time to respond.

How to Verify the Message:

Summarize the patient’s message by asking, “Let me make sure I understand” and by:

  • Repeating the message and/or
  • Adding gestures or writing down key-words and/or
  • Expanding what you think they were trying to say and/or
  • Giving a brief summary of longer conversations

Resources:

2. Free printable pictographs and templates to facilitate conversation – Aphasia Institute

3. About SCA. Communication Tools: Communicative Access & SCA – Aphasia Institute

4. Training. Introduction to SCA eLearning: a free, short online course – Aphasia Institute

5. Training. Training in SCA™ for Healthcare Professionals -In person (Canada)

Articles:
1. Training volunteers as conversation partners using “Supported Conversation for Adults with Aphasia” (SCA): a controlled trial


More Resources

The Adult Speech Therapy Workbook [Chung Hwa brewer, Miwa Aparo]

The Adult Speech Therapy Workbook
Hundreds of Worksheets & Handouts!

Complete Digital Adult Speech Therapy Workbook 9 PDF Packs image 0

Digital Speech Therapy Workbook
Printable PDF

SLP Evaluation Forms 6 Adult Eval Templates PDF Home Health image 0

Speech Therapy Evaluations for Adults
7 Evaluation Templates

Speech Therapy Reference Clipboard Illustrated medical SLP image 0

Medical SLP Clipboard
Dry-Erase

The Home Health SLP Handbook: Everything you need to provide speech therapy to adults in the home health setting. by [Chung Hwa Brewer, Miwa Aparo]

New to Home Health? Check out our book!

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