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Assessment and Treatment of Overview

Sentences in Aphasia: Evidence into • Background, definitions, and theory
Practice • Assessment of sentences

Break
Jiyeon Lee, PhD, CCC-SLP
Department of Speech, Language, and Hearing Sciences
Aphasia Research Laboratory • Treatment approaches
- MT, TUF, VNeST
- critical review

Aphasia Language disorder

• Acquired • Impaired processing of linguistic rules and
• Neurogenic representations
• Language disorder – Phonology
– Morphology
– Lexicon
– Syntax

Grammaticality Judgment Language Production Model

• The man is fixing the car.
• The man is fixing. Grammatical Encoding :
generation of semantic-
• The girl is sleeping the bed. syntactically specified
sentence form
• The girl is giving the teacher to the apple.
• Is melting the snowman.
• The dog is barking the man.
• The man is sending the letter to the woman.

Bock & Levelt (1994); Garret (1988)

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Grammatical Encoding Verb Argument Structure (VAS)

• Knowing a verb means knowing how many words are
“who does what to whom”
needed in the sentence and their thematic roles (e.g.,
Thematic (meaning) roles agent, theme).
e.g., Agent (do-er)
Patient/Theme (do-ee) e.g., sing [NPAgent [V]] fix [NPAgent [V NPTheme]]

VERB

Surface structure
active: det (N) aux (V) det (N)
passive: det (N) aux (V) by det (N)

• Successful comprehension and production of sentences

require correct assignment of thematic roles to the nouns
(arguments) associated with the verb.
Bock & Levelt (1994); Garret, 1988

Impaired Grammatical Encoding Agrammatic Aphasia

in Aphasia
• Pervasive • Often associated with Nonfluent/Broca’s
• Multiple underlying causes aphasia
• Systematic, rule-governed errors: • Relatively preserved comprehension:
– Verb argument structure complexity – Comprehension of syntactically complex sentences
– Canonicity in the mapping between meaning and is compromised.
word order • Impaired speech marked by reduced
grammatical complexity

Make a sentence for each picture. Verb Naming

A. B. C. A. B. C.

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VAS Complexity Effects VAS complexity

• Increased number of verb arguments,
greater impairment in sentence production and
verb naming (DeBlesser & Kauschke, 2003; Dragory & Bastiaanse,
2009; Kim & Thompson, 2000; Kiss, 2000; Luzzatti et al., 2002;
Thompson et al., 1997 and others).

•The man is sleeping (1-argument)

•The man is pulling the woman (2-argument)
•The man is giving the flowers to the woman (3-argument)

Kim & Thompson (2004)

VAS complexity Make a sentence for each picture.

A B.

Kim & Thompson (2004)

Name each action. VAS complexity effects

• Non-direct mapping of VAS, greater impairment in
A B. both sentence and single verb production (Bastiaanse &
van Zonneveld, 2004; Bastiaanse & Jonkers, 2005; Lee &
Thompson, 2004; Lee & Thompson, 2011; Kegl, 1995;
McAllister et al., 2009; Thompson, 2003)

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Production of unaccusative vs. Make a sentence in response to my

unergative sentences question.

Aphasics
Controls

Unaccusative (melt) Unergative (bark)

Lee & Thompson (2004). J of Neurolinguistics

Complex (Non-Canonical) sentences Canonical Sentence: Active

• Sentences with syntactic movement, greater
impairment (Bastiaanse & van Zonneveld, 2004; Bastiaanse & Jonkers,
2005; Lee & Thompson, 2004; Kegl, 1995; Schwartz et al., 1994; Rochon et al., Functional level: The boy (pull) the girl
2005; Thompson et al., 2003 and others). Thematic roles
Agent (do-er) Theme (do-ee)

• Syntactic movement: the theme (do-ee) is displaced Positional level: The boy
pulled
the girl
Surface order
from its original position (after the verb) and appears Subject position Object position
in the subject position.

Non-canonical sentence: Passive Complex (Non-Canonical) sentences

Simple sentences canonical order:
Active: the woman kissed the man.
Functional level: The boy (pull) the girl Subject Wh-Q: Who kissed the man?
Thematic roles
Agent (do-er) Theme (do-ee) Subject Relative: I saw the woman who kissed the man.
Subject Cleft: It is the woman who kissed the man.
Positional level: The girl was pulled by the boy
Surface order Complex sentences with object movement (non-
Subject position Object position canonical):
Passive: the man was kissed _____ by the woman.
Object Wh-Q: Who did the woman kiss _____?
* The thematic (meaning) roles of the nouns stay the same.
Object Relative: I saw the man who the woman kissed____.
Object Cleft: It is the man who the woman kissed____.

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Production of Canonical vs. Non-

canonical sentences Early encoding of VAS
100

90 • May be crucial for successful sentence

80

70 *
production (Lee, 2011; Lee & Thompson, 2011a; 2011b;
60
accepted; Lee, Yoshida, & Thompson, 2015).
50

40

• ‘Eye-tracking while speaking’ studies to

Older PD Aphasic

Canonical Non-canonical

Dick, Frederick, Man, & Lee (under review)

examine ‘when’ verb information is used
during sentence production.

Thompson et al. (2013), Behavioral Neurology

Production of verb arguments vs. adjuncts: Production of verb arguments vs. adjuncts:
Eyetracking while speaking Eyetracking while speaking

Argument condition Argument condition Adjunct condition

Adjunct condition

Goal argument Beneficiary adjunct

(modifier)

Goal argument Beneficiary adjunct

(modifier)

Lee & Thompson (2011b)

Lee & Thompson (2011b), Language and Cognitive Processes Language & Cognitive Processes

Gaze shifts between Verb and “baby” Summary

Control • GE is impaired in many IWA, characterized by systematic
speakers
errors
• Two important factors in predicting errors are the VAS
complexity and (Non) canonicity of the sentences
Stimulus “mother.....applying…. lotion…..... baby” • Early encoding of VAS may be critical for successful sentence
onset choosing
production and more beneficial for IWA with greater syntactic
impairments.
Agrammatic
speakers • The existing research evidence suggests that assessment and
treatment of sentence production should take these linguistic
variables into consideration.

Stimulus “mother..... applying….lotion…......baby”

onset choosing

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Rationale
• Many persons with aphasia (PWA) have ‘syntax’
problem, affecting processing of words, sentences,
and conversation in general.
Assessment of Syntax • Research support dissociated impairments among
different verbs and sentence types in IWA, which in
turn inform intervention strategies for these deficits.
• Take care in selecting assessment tools for verbs and
sentences
• The stimuli should be controlled for verb types and
sentence types at least.

Standardized Tests Standardized Tests

• Boston Diagnostic Aphasia Examination (BDAE, Goodglass, Kaplan,
& Barresi, 2001)
• Comprehensive Aphasia Test (CAT; Swinburn, Porter, & Howard,
2004)
• Object & Action Naming Battery (OANB; Druks & Masterson, 2000)
• Verb and Sentence Test (VAST; Bastiaanse, Edwards, & Rispens,
2002)
• Northwestern Assessment of Verbs and Sentences (NAVS,
Thompson, 2011)
• Northwestern Anagram Test (NAT; Thompson, Weintraub, &
Mesulum, 2012)

NAVS
• Strengths:
– A good test for syntax: selected portions can be used
– Good research support
– Controlled for word-retrieval difficulty for sentence-level
tests by providing written nouns and verbs, and using the
same nouns (man, woman, dog, cat) repeatedly.
– Affordable
• Limitations:
– Can be lengthy for administering the entire test (~40 min or
more)
– Not appropriate for severe patients.

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NAVS subtests
• Verb Naming Test
• Verb Comprehension Test
• Argument Structure Production Test
• Sentence Priming Production Test
• Sentence Comprehension Test

Practice:
NAVS administration and scoring
Argument Structure Production Test (ASPT)
Sentence Production Priming Test (SPPT)

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Northwestern Anagram Test

Treatment

Treatments Mapping Therapy (MT)

• Mapping Deficit Hypothesis (Schwartz et al., 1987):
• Mapping Therapy (MT) Agrammatic deficits arise from impaired
• Treatment of Underlying Forms (TUF) mapping between the functional (thematic roles,
• Verb Network Strengthening Training e.g., agent/theme) and positional processes
(VNeST) (surface word order, e.g., subject/object).

MT MT Protocol - Comprehension
(Schwartz et al., 1994)
• To strengthen mapping between the functional
(underlying semantic) and positional (surface • Pt is presented with a written sentence and
syntactic) processes. asked to read it aloud.
• Focus: identifying thematic roles of the nouns • Pt is trained to identify the verb and the
in relation to the verb. thematic roles of each noun in a varying order.
• Utilized for both sentence comprehension and • Immediate feedback is provided for each trial.
production deficits across various canonical
and non-canonical sentences.
Byng, 1988; Byng et al., 1994; Rochon, Laird, Bose, & Scofield, 2005; Schwartz,
Saffran, Pink, & Meyers, 1994; Marshall, 1995; and others

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MT protocol – Comprehension MT protocol - Comprehension

(Schwartz et al., 1994)
(Schwartz et al., 1994)

The woman is kissing the man. • 3 Phases:

• Phase A: Canonical sentences with action
Clinician prompts:
a. Read this sentence aloud.
verbs (e.g., call, hug)
b. Show me the verb (action word) in this sentence. • Phase B: Canonical sentences with ‘state of
c. Who is doing the kissing?
d. Who is being kissed?
mind’ verbs (e.g., like, love)
e. Client color codes the verb and different thematic roles for • Phase C: Noncanonical sentences with action
each step.
verbs
The order of c and d is varied across trials.

MT protocol – Production MT protocol – Production

(Rochon et al., 2005)

Target sentence: “The woman is kissing the man.” Target sentence: “The man is kissed by the woman.”

Clinician says: Clinician says:

• This is a picture about kissing. • This is a picture about kissing.

• The verb in this sentence is “kisses”
• In this picture the one doing the kissing is the
woman (Agent).
•The one who is being kissed is the man
(Patient)
• Please make a sentence starting with the
woman.
• The verb in this sentence is “kisses”
• In this picture the one doing the kissing is the
woman (Agent).
•The one who is being kissed is the man
(Patient)
• Please make a sentence starting with the
man.

Rochon, Laird, Bose, & Scofield (2005) Rochon, Laird, Bose, & Scofield (2005)

MT results MT protocol – Production

(Rochon et al., 2005) (Wierenga et al., 2006)

• When collapsed across sentence types, changes in performance were

significant for MT trained participants, but not for control participants.
• Treatment gains were generally maintained four weeks after tx. Color coded mapping template used to train active and passive sentences.
(Rochon et al., 2005: 18)

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Neural changes following MT

(Wierenga et al., 2006)
Treatment of Underlying Forms (TUF)

Increased activity
in Broca’s area • Linguistically-motivated Tx for training sentences
with syntactic movement (non-canonical)

• Complexity Account of Treatment Efficacy (CATE):

“Training more complex structure results in
recovery of untrained less complex, linguistically
Reduced activity
in lateral frontal related, structures”
regions

(Thompson et al., 2003)

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WH-movement structures TUF protocol

• Object wh-Q: • Identify verb and thematic roles of the
Who did the dog chase ___? verb arguments (nouns) in active form of
More complex

Generalization

• Object-cleft: target sentence (underlying functional

It is the boy [who the dog chased ___].
structure)
• Object Relative:
John saw the boy [who the dog chased ____]. •Move constituents to form the target
sentence (surface structure).
Complexity:
Object WH-Q < Object cleft < Object Relative
57 58

Step 1: comprehension probe

TUF Protocol
• Demo for Object Relative Tx “Point to Pete saw
the woman who
• See Thompson et al. (2003, Appendix B) for the man kissed.”
the treatment protocols for different sentence Incorrect response
types. is corrected by
clinician.
• TUF can be purchased:
http://anr.northwestern.edu/research/diagnostic
-tests/#TUF

59 60

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Step 2: Sentence production priming probe Step 3: Verb and verb argument comprehension

For this picture, I could say

“Pete saw the man who
the woman kissed”. For
this picture (pointing to the
target picture), you could
say…..?
who

Pete saw the woman the man kissed the woman

• An object relative construction is elicited using the sentence production
priming task.
• When pt fails to produce the target sentence, steps 3- 7 are followed.
61 62

Step 3: Verb and verb argument comprehension Step 4: Verb and verb argument production

1. Pointing to the verb of

1. “Point to the action
each clause: “name the
word”
action”
2. “point to the person
2. “Who saw?/ Who
who saw/kissed”
kissed?”
3. “point to the person
3. “Who was seen? /
who was seen/kissed”
Who was kissed”
who who

Pete saw the woman the man kissed the woman Pete saw the woman the man kissed the woman

63 64

Step 5: Object-relative clause formation (a) Step 6: Object-relative clause formation (a)
“Now we want to make
a new sentence, one
“Now we want to make
that combines these two
a new sentence, one
sentences. “
that combines these
two sentences.”
“The woman is the one
who was
“The woman is the one
kissed.”(Clinician
who was kissed.”
replaces ‘the woman’ who (Clinician replaces ‘the
with ‘who’)
woman’ with ‘who’)
“Now you read the
sentence for me.” “Read/repeat the
sentence for me.”

Pete saw the woman the man kissed the woman Pete saw the woman the man kissed who

65 66

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Step 6: Object-relative clause formation (b) Step 7. Patient practices steps 4-6

(Referring to the first

clause) “the woman • Sentence constituents are rearranged in their active
that Pete saw and the sentence form for each clause, together with the
woman the man kissed
are the same person. [who] card (as in Step 3).
So, we are going to
move them next to • Steps 4-6 are repeated, with the pt
each other”. replacing/selecting/moving the cards to form a
“Read the sentence for correct target construction.
me”
• Assistance is provided if needed.

Pete saw the woman who the man kissed

67 68

Participant (DL):
Generalization to
Generalization to simpler structures
untrained structures (Thompson & Shapiro, 2007)
(OC, WH?) following
OR-Tx
More than 20 individuals with
agrammatic aphasia trained:

85% of those who trained to

produce complex wh-movement
structures successfully generalized
to simpler wh-movement
Participant (HR): structures.
No generalization to
untrained structures.
Only 17% of individuals who
trained to produce wh-questions
showed generalization to more
Thompson et al. (2003) complex wh-movement structures.

69 70

Neural Changes following TUF Verb Network Strengthening

Training (VNeST)
• Aims to increase activation of a verb and its
thematic roles (agent-theme pairs) in order to
facilitate correct production of the words in
sentences.
• Generalization to untrained semantically
related verbs and their thematic roles is
expected via spreading activation in the
lexical network:
Thompson et al. (2010)

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Verb Network Activation VNeST protocol

(Edmonds & Babb, 2011) (Edwards et al., 2009)
• Step 1-2: Generate 3 agent-patient pairs for
verb.
Tell me who
can measure.

Tell me
what can be
measured.

• If pt cannot verbally provide the pairs, cards (including foils)

are provided from which the pt chooses plausible agents and
patients.

VNeST Protocol VNeST Protocol

• Step 3: Answer wh-questions about patient • Step 4: Semantic judgment of sentences
chosen agent-patient pair. • Cards removed from table
When does a
• Clinician reads 16 sentences containing the target
chef measure verb:
sugar? • 4 correct
• 4 with an inappropriate agent
Why? “in the morning” (e.g., the dentist measures the door)
“correct amount” • 4 with an inappropriate patient
Where?
“kitchen” • 4 with the agent and patient switched
• Client judges whether the sentences make sense or
not.

VNeST Protocol VNeST Results

• Step 5: Generation of 3 agent-patient pairs
(repeat steps 1–2)
• No cards used during Step 5, feedback is
general

Edmonds et al. (2009)

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Review of Treatment Efficacy Data

A Systematic Review of Verb-Centered • To systematically review treatment efficacy data of MT, TUF,
Treatments: Acquisition, and VNeST
– Acquisition of trained sentences
Generalization, & Maintenance – Generalization to untrained sentences
– Generalization to connected speech
– Maintenance of tx gains
Man, Dick & Lee (2015) • 25 peer-reviewed published studies located (9 TUF, 13 MT,
ASHA Convention and 5 VNeST)
• 4 MT and 1 VNeST studies excluded: no sentence production
probes for acquisition
• A total of 22 studies were included.
Man, Dick & Lee (2015)

Acquisition
• Production of trained sentences pre- vs. post-tx
TUF MT VNeST
• All three treatments showed high levels of
N 30 22 19
success.
Aphasia type 28 nonfluent, 21 nonfluent, 8 nonfluent,
97%
2 mixed 1 fluent 11 fluent
80%
Severity 25 mild-to- 2 mild, 1 mild, 74%
moderate, 20 moderate- 16 moderate,
5 severe to severe 2 severe

16/20 29/30 14/19

Generalization to untrained sentences Generalization to untrained sentences

Treatment Generalization to:
TUF untrained linguistically related simpler
structures (e.g., Object Relative > object
cleft, object wh-Q’s) 74%
71%
MT untrained simpler structures 59%
untrained verbs and arguments in trained
structures
untrained more complex structures

VNeST untrained semantically similar verbs and their

agent-patient pairs in sentence production 10/17 20/28 14/19
(e.g., measure  weigh)

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Generalization to connected speech Generalization to connected speech

• Narrative tasks: Cinderella, Cookie Theft,

Nicholas & Brookshire (1993)
• Successful generalization was judged as 88%

documented improvement in one of the 72%

52%
following:
– Informativeness (e.g., % CIU)
– Utterance length (e.g., MLU)
– Utterance complexity (e.g., % of complete
utterances, % of correctly produced complex 13/18 21/24 11/19

sentences, % of sentences with correct VAS)

Maintenance Summary
• Relatively successful acquisition effects for all Tx’s.
• Retention of the acquisition effects made in therapy
• Tx gains maintained when assessed.
• Measured at 1 to 5 months post-tx across studies
• Variable generalization to untrained stimuli and tasks.
• Not all studies measured maintenance.

100%
84%
74%

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Critical variables/limitations Critical variables/limitations

• Limited treatment/generalization effects in
participants with severe aphasia (WAB AQ < 50). • No more than moderate-to-mild apraxia of
speech.
• Not appropriate for patients with significantly
impaired comprehension or cognitive skills (Dickey • Little application for fluent aphasic patients.
& Yoo, 2010; Murray et al., 2004)
– Auditory comprehension was a significant predictor for
TUF outcomes, but not aphasia severity and complex • Tx-induced changes in quality of life rarely
sentence comprehension scores (Dickey & Yoo, 2010). assessed.

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MT studies included in our view:
• Byng, S., Nickels, L., & Black, M. (1994) Replicating therapy for mapping deficits in agrammatism:
Remapping the deficit? Aphasiology, 8:4, 315-341.
• Le Dorze, G., Jacob, A., & Coderre, L. (1991) Aphasia rehabilitation with a case of agrammatism: A partial
replication. Aphasiology, 5:1, 63-85.
• Marshall, J., Chiat, S., & Pring, T. (1997) An impairment in processing verbs’ thematic roles: A therapy
study. Aphasiology, 11:9, 855-876.
• Marshall, J., Pring, T., & Chiat, S. (1993) Sentence processing therapy: Working at the level of the event.
Aphasiology, 7:2, 177-199.
• Nickels, L., Byng, S., Black, M. (1991) Sentence processing deficits: A replication of therapy. British Journal
of Disorders of Communication, 26, 175-199.
• Rochon, E., Laird, L., Bose, A., & Scofield, J. (2005) Mapping therapy for sentence production impairments
in nonfluent aphasia. Psychology Press, 15, 1-36.
• Schwartz, M.F., Saffran, E.M., Fink, R.B., Myers, J.L., & Martin, N. (1994) Mapping therapy: A treatment
programme for agrammatism. Aphasiology, 8:1, 19-54.
• Weinrich, M., Boser, K.I., McCall, D., & Bishop, V. (2001) Training agrammatic subjects on passive
sentences: Implications for syntactic deficit theories. Brain and Language, 76, 45-61
• Wierenga, C.E., Maher, L.M., Bacon Moore, A., White, K.D., McGregor, K., Soltysik, D.A., Peck, K.K.,
Gopinath, K.S., Singletary, F., Gonzalez-Rothi, L.J., Briggs, R.W., &Crosson, B. (2006) Neural substrates of
syntactic mapping treatment: An fMRI study of two cases. Journal of the International Neuropsychological
Society, 12, 132-146.
VNeST studies included in our review:
• Edmonds, L. A., & Babb, M. (2011). Effect of verb network strengthening treatment in
moderate-to-severe aphasia. American Journal of Speech-Language Pathology,
20(2), 131-145.
• 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, 23(2), S312-
S329.
• Edmonds, L. A., Nadeau, S. E., & 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), 402-424.
• Furnas, D. W., & Edmonds, L. A. (2014). The effect of computerised Verb Network
Strengthening Treatment on lexical retrieval in aphasia. Aphasiology, 28(4), 401-420
• Laine, M., & Martin, N. (2006). Anomia: Theoretical and clinical aspects. New York,
NY: Psychology Press.
Thank you!
Questions/Comments?
4/19/2017
TUF studies included in our review:
• Ballard, K.J., & Thompson, C.K. (1999) Treatment and generalization of complex sentence production in
agrammatism. Journal of Speech, Language, and Hearing Research, 42, 690-707.
• Dickey, M.W., & Thompson, C.K. (2010) The relation between syntactic and morphological recovery in
agrammatic aphasia: A case study. Aphasiology, 21:6, 6-8, 604-616.
• Jacobs, B.J., & Thompson, C.K. (2000) Cross-modal generalization effects of training noncanonical sentence
comprehension and production in agrammatic aphasia. Journal of Speech, Language, and Hearing
Research, 43, 5-20.
• Murray, L., Ballard, K.J., & Karcher, L. (2004) Linguistic Specific Treatment: Just for Broca’s aphasia?
Aphasiology, 18:9, 785, 809.
• Thompson, C.K., Choy, J.J., Holland, A., & Cole, R. (2010) Sentactics: Computer-automated treatment of
underlying forms. Aphasiology, 24:10, 1242-1266.
• Thompson, C.K., den Ouden, D.B., Bonakdarpour, B., Girabaldi, K., & Parrish, T.B. (2010) Neural pasticity
and treatment-induced recovery of sentence processing in agrammatism. Neuropsychologia, 48, 3211-
3227.
• Thompson, C.K., Shapiro, L., Ballard, K.J., Jacobs, B.J., & Tait, M.E. (1997) Training and generalized
production of wh- and NP-movement structures in agrammatic aphasia. Journal of Speech, Language, and
Hearing Research, 40, 228-244.
• Thompson, C.K., Shapiro, L., Kiran, S., & Sobecks, J. (2003) The role of syntactic complexity in treatment of
sentence deficits in agrammatic aphasia: The complexity account of treatment efficacy (CATE). Journal of
Speech, Language, and Hearing Research, 46, 591-607.
• Thompson, C.K., Shapiro, L., & Roberts, M.M. (1993) Treatment of sentence production deficits in aphasia:
A linguistic-specific approach to wh- interrogative training and generalization. Aphasiology, 7:1, 111-133.
Conclusions
• Within a staged model of sentence production, grammatical
encoding processes are impaired in individuals with
(agrammatic) aphasia.
• Research evidence suggests that impaired processing of VAS
and non-canonical word order underlie these deficits.
• It is crucial to assess how these linguistic factors affect
sentence processing in IWA.
• A review of selected SP treatments show:
– Relatively successful acquisition and maintenance effects
(when assessed).
– Somewhat variable generalization to untrained stimuli and
tasks across treatments.
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