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Effect of Verb Network Strengthening
Treatment (VNeST) in Persons With
Aphasia: Extension and Replication
of Previous Findings
Lisa A. Edmonds,
a,b
Kevin Mammino,
a
and Jimena Ojeda
a,b
Purpose: Verb Network Strengthening Treatment (VNeST)
is an aphasia treatment that targets verbs (e.g., measure)
and their related thematic roles (e.g., carpenterlumber).
Previous studies reported encouraging results in a number of
participants using single-subject design with improvements
observed on naming, sentence production, and discourse.
The purpose of the current study was to conduct a group
analysis evaluating the effect of VNeST on similar outcomes.
Method: A multiple baseline design across participants
was conducted with 11 persons with aphasia due to stroke.
Wilcoxon signed-ranks tests were used to evaluate potential
improvement from pre- to posttreatment and maintenance.
Individual effect sizes were also calculated to evaluate
magnitude of change within and across participants.
Results: Results showed significant improvement at
posttreatment and maintenance on trained and untrained
sentence probes and object and action naming. Improvement
in the production of sentences not targeted in treatment was
nonsignificant at posttreatment assessment but significant
at maintenance. Moderate increases in percentage of
complete utterances and overall informativeness were
observed on discourse.
Conclusion: The results of this study replicate previous
findings and provide evidence that VNeST may promote
specific and generalized lexical retrieval abilities and affect
basic syntax production in both constrained and discourse
production tasks.
Key Words: aphasia, VNeST, verbs, treatment, thematic
roles, sentences, discourse
T
he most pervasive symptom in aphasia is anomia,
or difficulty retrieving words (e.g., Laine & Martin,
2006), which can affect language production at the
single word, sentence, and discourse level. The majority
of lexical retrieval treatment paradigms reported in the
literature have targeted single-word noun production, and
although generalization to improved retrieval of semanti-
cally related nouns has been observed across a number of
studies, generalization to sentences or discourse has been
negligible (see Kiran & Bassetto, 2008; Nickels, 2002).
Treatments targeting single verb retrieval have primarily
focused on provision of semantic and/or phonological cues.
Overall, improvement has been limited to trained verbs, with
virtually no improvement to untreated verbs, though some
improvement to sentence production and/or connected
speech has been reported in some studies. (For relevant
reviews, see Conroy, Sage, & Lambon Ralph [2006] and
Webster & Whitworth [2012].)
In an attempt to promote sentence production and
connected speech, a number of verb treatments have
integrated arguments into treatment. A subset of these
studies (as described by Webster &Whitworth, 2012) focused
primarily on sentence structure, syntax, and/or morphosyn-
tax (e.g., Bastiaanse, Hurkmans, & Links, 2006; Conroy,
Sage, & Lambon Ralph, 2009; Edwards & Tucker, 2006;
Links, Hurkmans, &Bastiaanse, 2010; McCann &Doleman,
2011; Raymer & Kohen, 2006). Trained tasks included sen-
tence completion and production and sentence production
cuing hierarchies. Overall, improvements were observed
for trained verbs, but there was limited improvement to
single-word retrieval of untrained verbs (Links et al., 2010;
Raymer & Kohen, 2006). Some improvements to sentence
a
Brain Rehabilitation and Research Center, Malcom Randall VA
Medical Center, Gainesville, FL
b
University of Florida, Gainesville
Correspondence to Lisa A. Edmonds: edmonds@ufl.edu
Editor: Swathi Kiran
Associate Editor: Yasmeen Faroqi-Shah
Received August 16, 2013
Revision received January 24, 2014
Accepted February 25, 2014
DOI: 10.1044/2014_AJSLP-13-0098
Disclosure: The authors have declared that no competing interests existed at the
time of publication.
American Journal of Speech-Language Pathology Vol. 23 S312S329 May 2014 A American Speech-Language-Hearing Association
Supplement: Select Papers From the 43rd Clinical Aphasiology Conference
S312
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production were reported (Bastiaanse et al., 2006; Edwards
& Tucker, 2006; Links et al., 2010; McCann & Doleman,
2011), with improvement to connected speech in a few
participants (Bastiaanse et al., 2006; Edwards & Tucker,
2006; Links et al., 2010). Although the improvements to
sentence production and connected speech are encouraging,
the gains observed in these studies were primarily structural
and/or grammatical (Webster & Whitworth, 2012), not
lexical.
As discussed in Webster and Whitworth (2012), the
degree of improvement to argument structure depends on
whether argument structure is lexically specified. If it is,
improvement will be restricted to treated verbs, but if it is
not, improvement in sentence production could be more
widespread. Thus, the lack of generalized lexical improve-
ment in these studies could reflect a focus on structure
without explicit semantic training. Promoting semantic
relationships between verbs and their thematic roles could
potentially promote more generalized improvement to
sentence production and discourse (e.g., Edmonds & Babb,
2011; Edmonds, Nadeau, & Kiran, 2009). Some studies have
attempted this with tasks such as identifying agents and
themes in pictures and picture description (Fink, Martin,
Schwartz, Saffran, & Myers, 1992), story production with
an emphasis on verbnoun associations (Kim, Adingono,
& Revoir, 2007), descriptions of a verbs semantics and
thematic roles (Schneider & Thompson, 2003), semantic
feature analysis (SFA) with verbs (which focuses on single
verbs but includes thematic roles) (Faroqi-Shah & Graham,
2011 [modified SFA]; Wambaugh & Ferguson, 2007;
Wambaugh, Mauszycki, & Wright, 2014), and tasks target-
ing associations between verbs and nouns, sometimes in
conjunction with sentence production (Webster & Gordon,
2009; Webster et al., 2005).
The overall results of these studies showed improve-
ment to trained verbs, but improvement to untrained verbs
was still not observed in the vast majority of the studies (but
see Object and Action Naming Battery [OANB] verb nam-
ing improvement in two participants in Faroqi-Shah &
Graham [2011]). For the studies that examined potential
generalization to sentence production, some observed
improvement only with sentences containing trained verbs
(Kim et al., 2007; Schneider & Thompson, 2003), while
others saw improvement with untrained verbs as well
(Webster & Gordon, 2009; Webster et al., 2005). Of the
studies that examined connected speech, only a few reported
improvement on lexical retrieval and/or improved syntax
or structure (Fink et al., 1992; Kimet al., 2007; Webster et al.,
2005). Although there is some evidence of generalization in
these studies, there is still limited improvement to untrained
lexical items. Verb Network Strengthening Treatment
(VNeST), the focus of the current study, is principally similar
to these treatments. However, there are some differences,
especially with regard to the scope of semantic training.
VNeST is a theoretically motivated treatment designed
to promote lexical retrieval in sentence contexts, with
potential generalization to more widespread lexical access
improvement (Edmonds et al., 2009). The fundamental
theoretical premise of VNeST is that semantic verb networks
are represented as neural networks that strengthen via
Hebbian learning through repeated activation and use
(Edmonds et al., 2009). A growing body of research with
young adults suggests that verbs and their related thematic
roles are neurally coactivated such that agents and patients
prime or 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 coacti-
vation between verbs (e.g., slicing) and their instruments (e.g.,
knife) (Ferretti et al., 2001; McRae et al., 2005; Park &
Edmonds, 2013) and priming fromlocations (e.g., restaurant)
to related verbs (e.g., eating) (Ferretti et al., 2001).
The treatment steps of VNeST followdirectly fromthis
theoretical framework. Participants are given a verb (e.g.,
measure) and are asked to retrieve related agents (doers of the
action, e.g., carpenter) and patients (receivers of the action,
e.g., lumber). Participants generate multiple pairs of agents
and patients per verb, thereby eliciting various event schemas
(e.g., carpenterlumber, chefsugar, seamstressfabric for
measure). Because a verbs conceptual meaning is somewhat
loose (relative to nouns) (Black & Chiat, 2003) and thus
can have different meanings based on its thematic roles,
generation of multiple agentpatient pairs actualizes various
dimensions of the verbs meaning. Retrieving verb schemas
also activates a large network of world, autobiographic, and
semantic knowledge that could potentially maximize gener-
alization of lexical retrieval to a relatively large corpus of
trained and untrained words in untrained language contexts
and tasks. Thus, the scope of semantic treatment is greater
than other treatments that target verbs and their thematic
roles, as multiple event schemas that can represent different
meanings or uses of trained verbs are not targeted in those
studies.
Another aspect of VNeST that is different from other
studies is that no pictures are used in treatment, so partic-
ipants cannot associate or learn responses related to pictures
(e.g., Webster & Gordon, 2009) but rather must search,
activate, and retrieve their own memories and representa-
tions. Participants also answer wh-questions (where, when,
why) about one scenario per verb to further develop the
schema and expand its saliency and relevancy. For the car-
penter measuring lumber example, a participant may discuss
that her bathroom was remodeled last summer because of
flood damage. Thus, VNeST requires divergent production
of multiple event schemas in a systematic way without being
limited by the entities and action represented in trained
pictures.
While VNeST attempts to engage a large semantic
network, treating verbs in conjunction with their thematic
roles also activates the syntactic elements of sentences (i.e.,
subjectverbobject) in a number of related ways. Because
argument structure is considered an integral part of a verbs
lexical representation, training them together potentially
strengthens both the verb representation and its connections
to its arguments. In addition, the repeated and diverse
selection of subjectagents and objectpatients potentially
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aids in mapping thematic role information onto syntactic
argument structure, which can be impaired in persons
with aphasia (e.g., Barbieri, Basso, Frustaci, & Luzzatti,
2010).
As indicated, extending improvement beyond trained
verb networks (i.e., generalization) is a fundamental aim
of VNeST. One component of that generalization is the
hypothesis that training one verb, such as drive, should
promote improvement to fly. This hypothesis is based on
(a) findings from previous semantic treatments for nouns
(e.g., Kiran & Thompson, 2003) and verbs (e.g., Raymer &
Ellsworth, 2002), (b) evidence that verbs prime semantically
related verbs (e.g., sweepdust) (Rsler, Streb, & Haan,
2001), and (c) results from previous VNeST findings
(Edmonds & Babb, 2011; Edmonds et al., 2009). Because a
verbs representation contains information about its argu-
ment structure and thematic roles, improved retrieval of not
only the untrained verb (e.g., fly) but also its associated
thematic roles is hypothesized (The pilot is flying the airplane;
for more details, see Edmonds & Babb, 2011). However,
there can be additional problems in sentence construction
beyond verb retrieval that can negatively affect sentence
production, such that improved verb retrieval (or argument
retrieval) may not support improved sentence construction
of untrained sentences for all participants (e.g., Berndt,
Mitchum, Haendiges, &Sandson, 1997; P4 in Edmonds et al.,
2009; Mitchum & Berndt, 1994).
In addition, more generalized improvement of lexical
retrieval abilities for single words and sentences unrelated
to treatment and discourse is hypothesized with VNeST
because of the wide range of concepts produced in treat-
ment (Edmonds et al., 2009), though individual participant
variables, including exacerbating cognitive and language
impairments, could certainly affect potential improvement
(see Lambon Ralph, Snell, Fillingham, Conroy, & Sage,
2010; Webster & Whitworth, 2012). Investigation of out-
come measures across a hierarchy of lexical retrieval tasks
may allow for insight into the extent of possible generaliza-
tion as well as patterns of improvement within and across
participants.
The current investigation builds on two previous
studies with VNeST. In the first study, four participants with
moderate aphasia (two fluent and two nonfluent) exhibited
generalization to sentence production for sentences con-
taining trained and untrained semantically related verbs in a
picture description task (Edmonds et al., 2009). All partic-
ipants also improved in sentence production on a test of
sentence production, and three of four participants improved
on single word noun and verb naming. Discourse also
showed an increase in complete utterances (relevant utter-
ances containing a subject, verb, and object) for three
participants. These findings showed evidence of a poten-
tial therapeutic effect (Robey, 2004) across participants to
untrained lexical items (response generalization) and tasks
(stimulus generalization).
The second study (Edmonds & Babb, 2011) was con-
ducted to provide insight into the potential target population
of VNeST by evaluating two women with moderatesevere
(Brocas) aphasia. P1 showed generalization to picture probes
on trained words with limited generalization to untrained
semantically related probes and no generalization on a test
of sentence production. However, P1 did improve on the
Western Aphasia Battery (WAB) and on single word naming
of nouns (but not verbs), with some evidence of improvement
in discourse. In addition, her mother reported improvement
on functional communication on the Communicative Effec-
tiveness Index (CETI; Lomas et al., 1989). P2, who had more
severe aphasia, showed more widespread improvement, with
gains on all outcome measures. She exhibited generalization to
both trained and untrained sentence probes, sentences unre-
lated to treatment, and single word noun and verb naming and
showed some signs of improvement on discourse. Further,
she improved on the WAB, and her mother indicated im-
provement in functional communication on the CETI. Al-
though there were some differences across participants, the
results suggest that participants with moderatesevere aphasia
may benefit from VNeST.
These first two VNeST studies demonstrated repro-
ducibility of improvement patterns across participants and
laid the appropriate groundwork to evaluate the effect of
VNeST in a larger group of participants, the focus of the
current study. Length of treatment was not controlled in
previous studies (a criterion measure was used). However, we
were able to estimate a reasonable dosage from previous
studies, allowing us to compare participants with each other
and as a group with consistent dosage. We kept the weekly
treatment intensity the same as in previous studies but stan-
dardized the number of sessions across participants by pro-
viding more sessions than in the first study with participants
with mildmoderate aphasia and fewer sessions than in the
study with participants with moderatesevere aphasia.
Our research questions were as follows:
1. Will provision of VNeST result in significant group
improvement to picture description on sentence probes,
which contain trained (e.g., chauffeurdrivelimousine)
and semantically related untrained (e.g., pilotfly
airplane) words?
2. Will there be significant group improvement to lexical
retrieval on untreated constrained tasks, including
confrontation naming of nouns and verbs (OANB;
Druks & Masterson, 2000) and sentences (North-
western Assessment of Verbs and Sentences [NAVS];
Thompson, 2011)?
3. Will there be significant group improvement to
discourse measures of lexical retrieval using Nicholas
and Brookshires (1993) stimuli?
4. Will there be significant group improvement to global
measures of aphasia severity (Western Aphasia Battery
Revised [WABR]; Kerstesz, 2006) and functional
communication abilities by proxy report (CETI)?
On the basis of the aforementioned theoretical support
for and previous findings from VNeST studies, we predicted
that the group would improve on all sentence and single-
word naming tasks. On discourse, we predicted improvement
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on our primary discourse measure, complete utterances
(Edmonds et al., 2009). We also predicted improvement on
percentage correct information units (CIUs), a measure of
informative words, from Nicholas and Brookshire (1993).
Although we were primarily interested in group results for
this study, we also report individual responses to treatment,
including effect sizes.
Method
Experimental Design
A multiple baseline approach across participants was
used with four phases: (a) baseline (probe testing; n = 5);
(b) treatment (biweekly probe testing; n = 5); (c) posttreat-
ment probes (n = 1 [because of time constraints in posttesting
for some participants] or n = 3); and (d) 3-month main-
tenance probes (n = 1). The probe task was sentence pro-
duction for pictures depicting trained (The carpenter is
measuring the lumber) and untrained semantically related
verbs (The farmer is weighing the apples). A control task was
administered during the same time points for demonstration
of experimental control. Additional outcome measures,
described below, were administered at posttreatment and
maintenance.
Participants
Treatment Participants
Eleven participants (mean age = 63.1, 7 males) with a
minimum of 12 years of education were recruited from the
Brain Rehabilitation and Research Center at the Malcom
Randall VAMedical Center in Gainesville, Florida, and from
Brooks Rehabilitation in Jacksonville, Florida. None of the
participants had participated in previous VNeST studies.
Participants met several inclusion criteria, including (a) di-
agnosis of aphasia based on the WABR (Kerstesz, 2006),
(b) monolingual English speaking, (c) right-handedness prior
to stroke, (d) negative history of diagnosed learning disorder
or drug or alcohol addiction, (e) maximum baseline aver-
age of 40% on the sentence probes, and (f ) no worse than
a composite score of a moderate deficit on the Cognitive
Linguistic Quick Test (CLQT; Helm-Estabrooks, 2001). All
participants had aphasia as a result of stroke. Nine of the
11 experienced a single left hemisphere ischemic stroke, one
(P3) had an aneurysm rupture during a clipping procedure,
and one (P4) had a left middle cerebral artery ischemic stroke
after two aneurysm ruptures. Finally, no participants exhib-
ited more than moderate apraxia of speech (AOS) on the
basis of their performance on the Apraxia Battery for Adults
Second Edition (Dabul, 2000) and on evaluation of McNeil,
Robin, and Schmidts (2009) characteristics of AOS. See
Table 1 for demographic details.
Six additional participants were evaluated. Five were
not included because they did not meet the inclusion and
exclusion criteria (e.g., multilingual, high scores on sentence
probes), and one chose not to enroll due to living too far
away.
Communication Partners
Ten treatment participants had a family member who
communicated with them regularly and agreed to complete a
questionnaire about the treatment participants communi-
cation. Eight of the 10 communication participants com-
pleted the Montreal Cognitive Assessment (Nasreddine et al.,
2005), and of those eight, seven scored within normal limits
(WNL) and were included in the study (the one who was
not enrolled scored 21/30 [with 26 considered WNL]). The
other two participants were not available to come to the
clinic for testing, but they were both below 60 years of age,
gainfully employed, and showed no signs of inability to
complete the questionnaire competently, so they were enrolled
without cognitive testing. Thus, 9 of the 11 treatment partic-
ipants had communication partners who were enrolled and
who completed the CETI (Lomas et al., 1989). Communica-
tion partners (7 women) included four spouses, three adult
children, one sibling, and one grandmother, with an average
age and education of 56.0 (SD = 17.5) and 14.1 (SD = 1.3),
respectively.
Materials
The following measures were administered to deter-
mine pretreatment language abilities and to serve as outcome
measures at posttreatment. Table 2 shows group scores,
and Table 3 shows individual scores.
Outcome Measures for Research Question 1
Sentence probe pictures. Sentence probe development
is discussed in Edmonds et al. (2009) and Edmonds and Babb
(2011). Briefly, 28 pictures were developed to elicit sentences
containing an agent, verb, and patient, where agents have
specific titles (e.g., nurse, carpenter) to promote specific
language (as opposed to general terms, such as woman, man).
A few additional sentences were added in this study, and
some previous sentences were reconfigured to ensure no
reversible sentences and no entities with general titles (e.g.,
boy, woman). Sentences were divided into sets, so that each
verb (measure) was semantically related to another verb
(weigh) across sets. See Supplemental Table 1 for details.
Control task. Two control tasks were administered to
participants during the baseline phase to rule out the pos-
sibility that improvements during treatment reflected a
nonspecific effect on semantic knowledge (i.e., to demon-
strate internal validity). The first was a single-word adjective-
retrieval task used previously (see Edmonds et al., 2009).
This task requires participants to complete 11 sentences by
providing a synonym to a provided adjective (e.g., Someone
who is sick is also said to be _____ [target: ill ]). Adjectives
were chosen rather than verbs, because a sufficient number of
verbs unrelated to treatment verbs and balanced across
psycholinguistic variables (e.g., frequency, length) could not
be generated (Edmonds et al., 2009). This is a conserva-
tive task, because participants are required only to provide
one word, and they are provided with a carrier phrase
that contains a synonym to the target word. However, this
task was hypothesized not to improve, because adjectives
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and features of objects were not explicitly trained. Further, a
similar task demonstrated control in a previous verb treat-
ment study (Marshall, Pring, & Chiat, 1998).
The second control task was the nonword repetition
task (Number 8) from the Psycholinguistic Assessment of
Language Processing (Kay, Lesser, & Coltheart, 1992). This
task was chosen because disproportionate nonword repetition,
as compared with real word repetition, has been reported in
aphasia (Rapcsak et al., 2009). The hypothesized mechanism
is a phonological deficit that disproportionately affects the
processing of unfamiliar phonological patterns (Rapcsak
et al., 2009). Because VNeST does not target phonology,
nonword repetition was not hypothesized to improve.
Procedures for Collecting Probe Data
and Administering Treatment
Probe and control measures. During baseline, the probe
pictures and control items were administered at the begin-
ning of each session and were audio- and video-recorded.
Pictures were presented pseudorandomly with semantically
related verbs (boilfry) in nonsequential order. For each
picture, participants were instructed to Make a sentence
and include him/her, the action, and this while pointing to
the agent (carpenter), verb (measure), and patient (lumber).
Prompts were not provided unless the participant produced a
general word for the target (e.g., cut instead of slice or man
instead of carpenter), for which a prompt for a more specific
word was given. After the baseline period, trained and
untrained semantically related verbs were chosen based on
the 10 sentence probe pairs that resulted in the lowest aver-
age starting point with similar averages for the trained and
untrained sets.
Transcription from audio files was conducted for all
probe responses. One point was awarded for each correct
agent, verb, and patient, with one phonemic error allowed
(e.g., bilot for pilot) per word. Grammatical and morpho-
logical errors were not penalized, because they were not tar-
geted in the treatment. If a response matched all three targets
for the agent, verb, and patient, then 1 point was given for the
total sentence score. Accurate alternative words were given
credit (e.g., logger for lumberjack, jet for airplane). To ensure
consistency in probe scoring, we conducted interrater reli-
ability for 100%of weekly probes. Apoint-to-point evaluation
showed 97% agreement in scoring.
Treatment materials and protocol. Treatment was
provided two times per week for 10 weeks, for a total of
20 sessions. Each session was 2 hr long. With time subtracted
for sentence probes during the treatment phase, participants
received approximately 35 hr of total treatment. (Because
of scheduling issues, P5 received only 18 sessions.) Ten verbs
were trained per participant, and each verb was trained 1 time
per week. See the Appendix for materials and protocol.
Outcome Measures for Research Question 2
Single-word lexical retrieval was evaluated with the
OANB (Druks & Masterson, 2000), which contains pictures
Table 1. Demographic and lesion information for all participants.
Pt M/F Age Ed Race MPO Aphasia type Stroke or lesion information
1 M 49 14 AfAm 61 Anomic Large left MCA CVA with changes in the left frontoparietal subcortical
white matter.
2 M 69 12 Cauc 74 Anomic Left frontal, temporal, and parietal CVA. Involved regions include
frontal operculum, triangular part of the frontal gyrus, superior
temporal gyrus, superior and middle frontal gyrus, precentral
gyrus, dorsolateral frontal cortex, perisylvian region, hand and arm
regions of primary motor cortex.
3 M 69 13 AfAm 144 Anomic Left posterior communicating artery aneurism rupture during a
surgery attempt to clip it. Left caudate head and internal capsule
involvement.
4 F 70 15 Cauc 15 Anomic Anterior communicating artery aneurysm, basilar tip aneurysm with
PCA ischemia, and subsequent left MCA CVA (embolism).
5 M 35 14 Cauc 59 Anomic Large left MCA CVA, thrombosis.
6 F 81 16 Cauc 72 Conduction Moderate-sized CVA in the left parietal lobe extending to the junction
of the temporal and parietal lobes.
7 M 63 18 Cauc 14 Conduction-Jargon Left MCA CVA. Left anterior temporal infarct extension to the
adjacent portions of the left parietal lobe and deep white matter of
the left frontal lobe, including the head of the caudate nucleus and
posterior insula.
8 M 61 18 Cauc 23 Conduction Moderate left CVA involving temporal lobe, parietal lobe, and part of
the left frontal lobe, including the insular cortex.
9 F 68 16 Cauc 95 Wernickes Large left MCA CVA involving mid- to peripheral distribution of the
MCA with vascular compromise to the periphery of the parietal
lobe and portions of the periphery of the temporal lobe.
10 F 58 15 Cauc 26 TCM Large left anterior division MCA CVA.
11 M 71 22 Cauc 16 TCM Moderate-sized left MCA CVA involving the left frontal lobe, insular
cortex, and left basal ganglia.
Note. Pt = participant; M = male; F = female; Ed = education; MPO = months postonset; AfAm = African American; Cauc = Caucasian;
TCM = transcortical motor aphasia; MCA= middle cerebral artery; CVA = cerebrovascular accident; PCA = posterior cerebral artery.
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of objects (N = 162) and actions (N = 100). The object and
action stimuli are divided into two forms (A and B) that are
balanced for psycholinguistic (e.g., frequency, age of acqui-
sition) and nonlinguistic (e.g., imageability, visual com-
plexity) variables. All participants completed both forms,
and no cues or feedback were given.
Lexical retrieval in sentences was evaluated with
stimuli from the Argument Structure Production Test from
the NAVS (Thompson, 2011). Verbs included one-, two-,
and three-place verbs (e.g., The dog is barking; The woman
is kissing the man; The man is putting the box on the shelf ).
The NAVS protocol requires showing and reading the verb
to the participant, but we did not do either; rather, par-
ticipants just saw the pictures and made a sentence. Further-
more, the test contains two- and three-place verbs in optional
(The man is sweeping) and obligatory contexts (The man
is sweeping the dirt), but we tested only the more complex
sentence to avoid multiple presentations. Thus, 36 of
50 pictures were administered (one-place, n = 8; two-place,
n = 17; three-place, n = 11).
For OANB and the NAVS, scoring was conducted
according to the test manuals, though one phonemic error
per lexical item was allowed. One hundred percent reliability
was conducted (point to point) for both measures, with an
average scoring agreement of 96.5%.
Outcome Measures for Research Question 3
Participants responded to all 10 discourse elicitation
materials from Nicholas and Brookshire (1993), which
include procedural, personal, single-picture, and sequential-
picture stimuli. Participant responses were blinded and then
transcribed using Systematic Analysis of Language Tran-
scripts software (Miller & Iglesias, 2012). Utterances were
broken into T-units, or a main clause with its subordinate
Table 2. Group statistics details and results for tasks corresponding to all research questions evaluated at posttreatment and 3-month
maintenance.
Generalization measure
Pre-tx mean
(SD)
Post-tx mean
(SD) Wilcoxon Z p
Pre-tx mean
a
(SD)
Maintenance
(SD) Wilcoxon Z- p
Research Question 1
Sentence probes
SentencesTR (n = 10) 20.4% (13.3) 58.8% (33.9) 2.803 .005 20.4% (13.3) 56.0% (29.9) 2.705 .007
SentencesUT (n = 10) 19.8% (11.0) 40.9% (24.9) 2.703 .007 19.8% (11.0) 43.0% (27.5) 2.805 .005
WordsTR (n = 30) 58.5% (11.1) 80.7% (17.0) 2.803 .005 58.5% (11.1) 80.3% (13.5) 2.805 .005
Agents (n = 10) 57.6% (21.6) 84.7% (19.6) 2.803 .005 57.6% (21.6) 86.0% (18.4) 2.805 .005
Verbs (n = 10) 52.4% (16.1) 74.0% (21.8) 2.395 .017 52.4% (16.1) 68.0% (25.3) 2.492 .013
Patients (n = 10) 65.6% (17.4) 83.5% (18.6) 2.703 .007 65.6% (17.4) 87.0% (10.6) 2.654 .008
WordsUT (n = 30) 59.8% (10.0) 73.1% (15.5) 2.701 .007 59.8% (10.0) 73.3% (14.7) 2.701 .007
Agents (n = 10) 63.6% (21.9) 74.3% (19.9) 2.075 .038 63.6% (21.9) 76.0% (21.2) 1.994 .046
Verbs (n = 10) 49.4% (16.7) 61.3% (22.6) 1.779 .075 49.4% (16.7) 64.0% (23.2) 2.668 .008
Patients (n = 10) 66.4% (12.8) 83.7% (14.2) 2.803 .005 66.4% (12.8) 79.0% (16.6) 2.293 .022
Control 34.7% (14.5) 42.0% (18.0) 1.838 .066 34.7% (14.5) 36.6% (20.4) 0.841 .400
Research Question 2
Single words and sentences
OANBnouns (n = 162) 79.91% (12.3) 85.07% (12.6) 2.402 .016 N/A N/A N/A N/A
OANBverbs (n = 100) 64.64% (18.2) 74.18% (16.0) 2.668 .008 N/A N/A N/A N/A
NAVS sentences (n = 36) 29.04% (23.7) 42.42% (25.6) 1.719 .086 29.04% (23.7) 40.15% (23.8) 2.807 .005
Research Question 3
Discourse
% Comp utterances 39.73 (11.9) 46.74 (16.0) 2.223 .026 40.85 (11.9) 47.98 (13.8) 1.580 .114
Number of words 922.18 (584.2) 1,036.82 (638.4) 1.156 .248 986.80 (572.9) 1,093.40 (546.6) 0.764 .445
Number of CIUs 408.45 (251.0) 469.91 (269.1) 1.682 .093 438.80 (242.4) 538.70 (281.2) 1.955 .051
% CIUs 46.63 (11.8) 48.70 (13.8) 0.622 .534 47.49 (12.0) 51.42 (13.3) 1.988 .047
CIUs per minute 27.69 (15.1) 28.90 (16.6) 0.978 .328 29.55 (14.5) 33.51 (21.4) 0.764 .445
Number of utterances 132.18 (69.3) 143.36 (85.1) 0.408 .683 141.20 (65.9) 142.90 (74.2) 0.415 .678
% Pauses 37.39 (24.0) 35.74 (24.4) 0.978 .328 34.52 (23.3) 33.82 (24.2) 0.663 .508
% Mazes 10.99 (5.6) 10.71 (5.5) 0.712 .477 10.00 (4.7) 10.93 (5.2) 0.868 .386
Research Question 4
Aphasia severity:
WAB AQ 75.91 (10.4) 82.12 (8.6) 2.395 .017 N/A N/A N/A N/A
Functional communication:
CETI (N = 100 possible) 32.61 (9.7) 65.28 (11.2) 2.666 .008 32.61 (9.7) 58.29 (15.6) 2.666 .008
Note. Data in bold were significant at the p < .05 level. tx = treatment; TR = trained; UT = untrained; OANB = Object and Action Naming Battery;
NAVS = Northwestern Assessment of Verbs and Sentences; Comp = complete; CIU = content information unit; WAB AQ = Western Aphasia
Battery Aphasia Quotient; CETI = Communication Effectiveness Index; N/A = not applicable.
a
An additional Pre-tx column is present because of a different number of participants that were evaluated at maintenance than at posttreatment.
Edmonds et al.: Verb Network Strengthening Treatment S317
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S318 American Journal of Speech-Language Pathology Vol. 23 S312S329 May 2014
Downloaded From: http://ajslp.pubs.asha.org/ by a Proquest User on 06/09/2014
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.
Edmonds et al.: Verb Network Strengthening Treatment S319
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clauses. Pauses 2 s were coded, and mazes, which were
defined as any filled pause (e.g., uh, um), false start (e.g.,
b* b*), or part word (e.g., fir*), were also transcribed and
coded.
Transcriptions were coded for number of words and
CIUs (Nicholas & Brookshire, 1993), from which percentage
CIUs (% CIU), CIUs per minute, and words per minute
(WPM) were calculated. Complete utterances, which contain
both a complete sentence frame and relevance to the topic
(Edmonds et al., 2009), were also coded. A complete sen-
tence frame [+SV] was defined as an utterance containing a
subject, verb, and object (S-V-O). Grammatical, morpho-
logical, and phonemic errors were acceptable, as these were
not targeted in treatment and are not penalized according
to Nicholas and Brookshire (1993).
Relevance of utterances [+REL] was determined by
evaluating whether the entire S-V-(O) segment was relevant
to the topic. Multiple utterances with identical meaning
and containing no new information were considered relevant
only the first time. Thus, a complete utterance [+COMP]
had to be coded as both [+SV] and [+REL] as shown by the
following examples (Edmonds et al., 2009):
1. The tree is open [+SV][REL][COMP].
2. A little guy with some sand on the shore with his hands
the sand [SV][+REL][COMP] (missing main verb).
3. To walk through the step [SV][REL][COMP].
4. The son is flying is a kite [+SV][+REL][+COMP].
Once coding was complete, percentage of complete
utterances was determined. Reliability for transcription and
coding was done on 100% of transcripts. Transcript reli-
ability was 96%, and coding reliability ranged from 92% to
96% across coding types.
Outcome Measures for Research Question 4
The WABR (Kerstesz, 2006) was administered to
determine presence and severity of aphasia. The CETI
(Lomas et al., 1989) questionnaire was used to gather proxy
ratings of functional communication. The responses to the
16 questions are represented on a visual analogue scale,
which participants mark from Not at all able to As able as
before stroke along a 100-mm line. The higher the line is
marked, the more as able as before the stroke the commu-
nication is rated. A range of communication scenarios are
represented, including communicating physical problems such
as aches and pains and being part of a conversation when it
is fast and there are a number of people involved.
Additional Testing
The following tests were administered to provide a
more comprehensive picture of pretreatment cognitive and
linguistic abilities and potentially to provide insight into
responses to treatment across participants. They were also
administered posttreatment but were not evaluated as out-
come measures.
The CLQT (Helm-Estabrooks, 2001) was adminis-
tered as a screen for cognitive impairments. All participants
achieved a composite score of a moderate deficit or better
with a range of abilities across the five subtests (Attention,
Memory, Executive Function, Language, and Visuospatial
Skills). See Table 4.
Semantic processing of objects and actions was tested
using the pictures in Pyramids and Palm Trees (Howard &
Patterson, 1992) and Kissing and Dancing (Bak & Hodges,
2003). For both tests, participants point to one of two items
that goes best with the target item (e.g., eyes for eyeglasses
rather than ears). To reduce testing burden at posttreatment,
we did not readminister these tests if participants scored
within normal limits at pretesting ( 47 points for each).
See Table 4.
The Sentence Comprehension Test from the NAVS
(Thompson, 2011) was administered to examine compre-
hension of sentences controlled by syntactic complexity. The
test contains 30 items, including active and passive sentences,
subject- and object-extracted wh-questions, and subject
and object relatives. See Table 4 for results.
Treatment Training and Reliability
Three licensed speech-language pathologists with
extensive clinical (830 years) and research experience with
aphasia conducted the treatment at the Malcom Randall VA
Medical Center in Gainesville, Florida, and Brooks Rehab-
ilitation in Jacksonville, Florida. Clinicians received com-
prehensive training from the first author, which included
review of a comprehensive treatment manual, videos of
VNeST being delivered, and practice conducting VNeST.
They were also given answer sheets and checklists to ensure
proper administration of VNeST. Once clinicians exhibited
thorough knowledge and ability, they began treatment with
participants.
To ensure consistency in execution of the treatment
protocol, the first author watched 25% of the treatment
sessions live or on video and determined whether each step
was conducted correctly. Clinicians were made aware of any
discrepancies between the treatment protocol and execution.
Percent reliability was calculated by dividing the total
number of steps that were conducted correctly by the total
number of steps observed. The treatment protocol was
followed with a reliability of 95.3%.
Analysis and Results
A Wilcoxon signed-ranks test was conducted to
determine whether there were significant (p < .05) group
changes frompre- to posttreatment on all measures and from
pretreatment to maintenance (3 months) for sentence probes,
NAVS, and discourse. Given the relatively small sample size
and the diversity of participants linguistic profiles, we also
provide individual participants scores. In order to interpret
individual changes, we used normative reference samples,
when available. For measures without normative references,
effect sizes were calculated. Details are provided below
and in tables. Finally, there were two instances of missing
data: no posttreatment WABR or sentence probe results
S320 American Journal of Speech-Language Pathology Vol. 23 S312S329 May 2014
Downloaded From: http://ajslp.pubs.asha.org/ by a Proquest User on 06/09/2014
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Edmonds et al.: Verb Network Strengthening Treatment S321
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for P8 because of researcher error and no maintenance
discourse for P4 because of illness.
Research Question 1: Improvement to Sentence
Probes Containing Trained and Untrained Verbs
Sentences containing trained and untrained words
improved significantly from pre- to posttreatment, and these
improvements were maintained 3 months after completion of
treatment. No improvement was observed on the control
task, as hypothesized, at posttreatment or maintenance
(p > .05). See Table 2.
During the baseline phase, most participants scored
too high on the nonword repetition task to allow for po-
tential improvement. Thus, the adjective control task was
used for all but two participants, P6 and P5. For P6, the
two-syllable nonwords (n = 10) were used from the repeti-
tion task. P5, who had a mild anomic aphasia with high
confrontation naming scores on other pretesting measures,
scored too high on both control tasks, so forward and
backward digit span were used for his control.
All participants averaged less than 50% accuracy
across all baseline probes. However, P1 and P4 exhibited
variability during the baseline phase and had individual data
points equaling 63.6%, thereby leaving less chance for po-
tential improvement. A post hoc examination of the post-
treatment control results shows that P1 did not exhibit
improvement. P4 showed miminal improvement on the
control task by repeating one nonword at posttreatment
that was not produced during baseline. See sentence probe
and control data for all participants in Supplemental
Table 2.
Although it was not an a priori research question, we
were interested in what components of the probe sentences
improved. Virtually all words showed significant improve-
ment posttreatment and at maintenance. See Table 2 for
details.
Effect sizes for trained and untrained sentence probes
were calculated for each participant. We used Cohens d
calculation (Cohen, 1988; d = M
2
M
1
/s, where M = the
mean, and s = the standard deviation at pretreatment). If the
pretreatment standard deviation was zero, the trained and
untrained scores were pooled to calculate a nonzero standard
deviation. When no existing effect size benchmarks exist
for a specific task, it is optimal to estimate effect sizes from
the task itself, if possible (Robey, Schultz, Crawford, &
Sinner, 1999). Thus, we used the effect sizes from the par-
ticipants in this study to calculate estimated benchmarks. To
calculate benchmarks for trained sentence probes, we cal-
culated the first, second, and third quartiles for all the effect
sizes from the trained sentence probes (Beeson & Robey,
2006), and those values (2.3, 3.7, and 5.5) were designated as
small, medium, and large effects. Because using the same
effect sizes for trained and untrained probes is not advisable
(Beeson & Robey, 2006; Robey et al., 1999), we calculated
separate benchmarks for the untrained sentence probes
and got slightly lower cutoffs (1.2, 1.7, and 3.3) for small,
medium, and large effects. See Table 5 for effect sizes.
Research Question 2: Confrontation Naming
of Object and Actions on OANB and
in Sentences on NAVS
OANB
There was a significant increase in noun and verb
naming accuracy on OANB. See Table 2. To interpret
individual naming changes, we used the standard deviations
provided in the OANB manual from a group of cognitively
normal older adults (there are no comparable measures
for people with aphasia). A standard deviation of 1.87 was
reported for nouns, 2.40 for verbs. Using two standard
deviations, an increase of 4 or more noun responses or 5 or
more verb responses was used as an indicator of improve-
ment. See Table 3.
To further refine our results, we adjusted OANB scores
by removing any words that happened to be trained during
treatment or seen in trained sentence probes (30 possible
words: 10 trained verbs [e.g., writing] and 20 corresponding
agents and patients [e.g., pipe]) to determine whether OANB
improvements were due to training and not necessarily an
indication of generalization. Once we removed the overlap-
ping items (37 nouns and verbs across participantsnot
all participants were trained on the same verbs), we recal-
culated percent correct accuracy. The pre- and posttreatment
scores (pre- and posttreatment nouns: 79.75% [12.57] and
84.84% [12.80], respectively; pre- and posttreatment verbs:
64.68% [18.48] and 73.24% [38.30], respectively) were vir-
tually the same as those with all items included, and post-
treatment significance was maintained for nouns (p = .016)
and verbs (p = .007) (see Table 2).
NAVS
A significant increase in the production of sentences
at posttreatment was not observed (p = .086), though there
was an increase in average accuracy from 29% to 42.4%.
However, a significant increase was observed from pre-
treatment to 3-month maintenance (p = .008). See Table 2
for group results.
Similar to the OANB, we wanted to ensure that the
improvement on the NAVS was not due to improvement
on items that were trained. Thus, we removed the results of
any sentences that contained a trained item (e.g., shaving,
driving; range was 26 across participants) and recalculated
the results. The results were similar to our original findings
with pre- to posttreatment not being significant (p = .075)
despite an increasing trend in percentage correct (pre: 26.88%
[24.81]; post: 40.46% [27.05]). Maintenance results were
similar to the original results (Table 2) as well (37.41% [26.13];
accuracy, p = .010).
The NAVS and the measure of complete utterances
used for discourse (discussed below) do not have normal
reference measures to interpret individual change after
treatment. Thus, we calculated effect sizes using Cohens d
(Cohen, 1988) with a pooled group standard deviation.
There was more variability in the group pretreatment scores
as compared with individual sentence probe baseline scores,
resulting in much lower effect sizes for the group statistics.
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For these measures, Cohens (1988) benchmarks of 0.5 and
0.8 as medium and large effects were used. See Table 5 for
all effect sizes.
Research Question 3: Lexical Retrieval in Discourse
The primary discourse measure was percentage of
complete utterances, which increased significantly from pre-
to posttreatment with no change in number of utterances.
At maintenance, percentage of complete utterances did not
maintain significance despite a similar average compared
with posttreatment. This loss of significance may be due
to lower power at maintenance (n = 9) as compared with
posttreatment (n = 11).
In addition to percentage of complete utterances, we
examined potential lexical retrieval improvement at the word
level with % CIU. We also evaluated potential changes in
efficiency with CIUs per minute and WPM (Nicholas &
Brookshire, 1993). We used the standard error of the mean
values reported for the aphasia group in Nicholas and
Brookshire (1993): % CIU SEM = 2.0; CIUs/min = 4.0;
WPM = 6.2. Changes of more than two standard errors of
the mean were used as an indicator of improvement. No
group changes were observed for any of these measures. Per-
cent pauses and mazes were also evaluated, with no changes
observed. See Tables 2 and 3.
Research Question 4: WABR and CETI
Posttreatment aphasia quotients improved signifi-
cantly from an average of 75.91 to 82.12 (p = .017), with
seven of the 10 participants exhibiting clinically significant
improvement (5 points; Katz & Wertz, 1997). See Tables 2
and 4. Average scores for the CETI showed a significant
increase from pre- to posttreatment and 3-month mainte-
nance. Changes for all participants at both time points
surpassed the retest standard error of the mean of 5.2 es-
tablished during CETI development (Lomas et al., 1989).
See Tables 2 and 3.
Discussion
Previous studies with VNeST (Edmonds & Babb,
2011; Edmonds et al., 2009) using single-subject design
Table 5. Effect sizes for sentence probes, control task, NAVS sentence production, and complete utterances for all participants.
Posttreatment Maintenance
Sentence probes
a
Sentence probes
a
Pt TR UT Control
b
TR UT Control
b
1 6.22*** 4.92*** 0.15 6.22*** 9.39*** 0.92
2 2.02 3.03** 0.94 3.56* 3.82*** 0.
3 2.92* 1.10 0.67 4.75** 1.10 0.11
4 7.81*** 4.15*** 2.68** 6.22*** 1.23* 1.57*
5 3.69** 3.54** 0 3.69** 4.24*** 0.
6 8.21*** 1.65* 0.66 3.82** 2.83** 0.61
7 2.62* 1.23* 0.94 3.83** 0.35 1.23*
8 DNT DNT DNT DNT DNT DNT
9 1.95 1.91
c
0.94 1.10 1.91
c
1.23*
10 4.62** 1.43* 0.56 1.40 1.43* 2.62
11 0.18 0.45 3.80*** 2.92* 0.67 1.57*
Posttreatment Maintenance
Pt % NAVS Sent Production
d
% Complete Utterances
d
% NAVS Sent Production
d
% Complete Utterances
d
1 0.00 0.25 0.12 0.69**
2 0.34 1.03 0 1.05
3 0.56** 0.85*** 0.60** 1.01***
4 1.35*** 0.07 0.23 N/A
5 0.11 1.53*** 0.23 1.17***
6 1.69*** 0.22 0.36 0.18
7 1.58*** 0.01 1.07*** 0.08
8 0.23 1.51*** 0.71** 0.79**
9 0 1.09*** 0.12 1.12***
10 0.56 0.78** 1.19*** 1.08***
11 1.35*** 0.21 0.60** 0.11
a
Bolded items for sentence probes indicate small*, medium**, or large*** effect sizes as compared with pretreatment.
b
Controls with bolded
effect sizes did not improve over the highest point at baseline (P7, P9), improved by 1 point (P4), or improved by 2 points (P11; he showed no
treatment effect on probes).
c
We did not note the medium effect of this value because of apparent inflation of the effect size due to a low standard
deviation calculation.
d
Bolded items for NAVS Sentence Production and %complete utterances indicate mediumand large effect sizes compared
with pretreatment.
*p < .05. **p < .01. ***p < .001.
Edmonds et al.: Verb Network Strengthening Treatment S323
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reported encouraging results in six participants. The current
group study showed significant improvement on production
of sentences containing trained and untrained semantically
related stimuli, replicating previous findings. Improvement
on trained verb probes indicates that trained verb networks
were sufficiently activated during treatment to allow gener-
alization to picture description, an untrained task. It was
hypothesized that such improvement would occur because
of strengthened connections between the trained verb and
related agentpatient combinations. Other researchers have
argued that such improvement could potentially be due to
increased awareness about verbs and/or a general strategy to
specify arguments around verbs (e.g., Marshall et al., 1998),
improved efficiency in verb retrieval (e.g., Conroy et al.,
2006), or, similarly, a freeing up of resources to facilitate
improved sentence retrieval (Linebarger, McCall, & Berndt,
2004). Although these explanations are certainly possible,
the improvement to untrained semantically related probes
indicates more generalized semantic improvement and,
potentially, generalization of improved structuralsyntactic
abilities for simple sentences.
Because VNeST aims to promote widespread lexical
retrieval abilities through activation of a multitude of diverse
event schemas, our outcome measures evaluated lexical
retrieval across a hierarchy of tasks. Group improvement
was observed on both object and action naming on OANB
(Druks & Masterson, 2000), indicating improved access to
and lexical retrieval of untrained object and action concepts.
The majority of participants also exhibited generalized
improvement to NAVS sentences. These findings, along with
those from previous studies, support the hypothesis that
VNeST may promote generalization of sentence production
abilities beyond treated concepts and tasks (response and
stimulus generalization, respectively). Presumably, im-
provement beyond trained networks occurred, at least in
part, because of increased lexical retrieval. However, ade-
quate sentence frame construction abilities are important for
integrating improved lexical retrieval into sentences (see
Webster & Whitworth, 2012). It is conceivable that VNeST
tasks, such as agent and patient retrieval around a trained
verb and reading aloud the agentverbpatient responses in
canonical order, may have strengthened both lexical retrieval
and basic sentence construction abilities. Participants who
did not improve on the NAVS may have had impairments
in constructing a sentence frame requiring more explicit
syntactic treatment in addition to the lexical retrieval tasks,
as they all improved on OANB naming but not on NAVS
sentences.
Connected speech improved from pre- to posttreat-
ment on percentage of complete utterances, suggesting
improved integration of relevant content words into a com-
plete sentence frame. We also hypothesized improvement
on % CIUs, a measure of relevant lexical retrieval. One
possibility for the lack of % CIU improvement could be a
tradeoff between improved lexical retrieval within utterances
and increased informativeness overall. However, the find-
ings do not support this, as four of the five participants
who improved on % CIUs also improved on percentage of
complete utterances, thereby increasing the proportion of
informative content while also integrating relevant words
more fully into sentence frames. Two additional participants
improved on percentage of complete utterances but not on
% CIUs, and one participant improved only on % CIUs.
Thus, about a third of participants showed no improvement
on discourse, a third showed improvement in either infor-
mativeness or complete utterances, and a third showed
improvement to both informativeness and sentence produc-
tion. Variable improvement on discourse within and across
participants is commonly reported in verb treatments
studies (e.g., Edwards, Tucker, & McCann, 2004; Fink et al.,
1992; Links et al., 2010; Schneider & Thompson, 2003;
Webster et al., 2005) and is not surprising, given that dis-
course requires the integration of cognitive (e.g., attention),
micro-linguistic skills (e.g., lexical retrieval, syntax), and
macro-linguistic skills (e.g., coherence and cohesion). Thus,
the persistent finding of variable outcomes in connected
speech across studies is likely a reflection of the diversity and
complexity of participant impairment patterns, the scope
and focus of treatment protocols, and the outcome measures
used to evaluate improvement (see Conroy et al., 2006;
Webster &Whitworth, 2012). However, the participants who
did not improve on discourse in the current study showed
improvement on some combination of the other generaliza-
tion tasks, suggesting a response treatment that did not gen-
eralize to or was not captured in our outcome measures. In
future studies, we plan to refine pretreatment testing measures
to better characterize impairment patterns and diversify
discourse outcomes to better capture potential improvement.
More global language abilities were measured on the
WABR and the CETI. WABR scores improved signifi-
cantly across the group, with 7 of the 10 participants showing
a clinically significant improvement (Katz & Wertz, 1997).
Increases in the WABR score corresponded to improve-
ments in Production and/or Comprehension subtests. For all
but one (P9, who has Wernickes aphasia) of those who
improved on WABR comprehension, comprehension also
improved on NAVS sentences. Although VNeST does not
explicitly target comprehension, this improvement may be
related to participants having to respond to many questions,
including wh-questions, during treatment.
The responses from communication partners on the
CETI reflect the perception of improved functional com-
munication of treatment participants from pre- to post-
treatment and maintenance. To ensure that communication
partners would not be influenced by their initial scoring,
we did not provide them with their pretreatment responses
at posttreatment or maintenance (which is different from
the CETI protocol). Unsolicited responses from participants
families also revealed functional communication changes.
P4s spouse reported the following regarding her ability to
participate in her medical care: You guys helped her speech
and communication so much. She was talking in complete
sentences when she was done with it. When she got the
diagnosis of [omitted for privacy], she was able to talk to us.
She was able to ask the doctors questions and participate
in her medical plan. That was so very important to us. See
S324 American Journal of Speech-Language Pathology Vol. 23 S312S329 May 2014
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additional family comments in Supplemental Table 3. Please
note that we acknowledge that proxy and anecdotal report
are not direct evaluations of functional communication.
However, combined with the impairment-based results, it is
conceivable that participants experienced some improved
communication abilities outside of the clinic.
Because VNeST-related improvements are assumed to
be, at least in part, due to activation of a large number of
diverse event schemas, we evaluated actual responses to
verify that participants were, in fact, producing a variety
of responses. We found that participants produced a large
number of novel agents and patients throughout the course
of treatment (first half: 52 agents and 48 patients: second
half: 44 agents and 46 patients). That is, the 52 agents and
48 patients produced in the first half of treatment were not
produced again in the second half of treatment, and those
novel 44 and 46 agents and patients produced in the second
half were not produced in the first half. Participants also
produced an additional 46 agents and 46 patients across both
halves of treatment, totaling 145 agents and 138 patients
produced during treatment.
We also examined the nature of responses and found
that participants produced a diverse mix of scenarios, in-
cluding prototypical (e.g., quarterbackthrowsfootball,
womancarriespocketbook, oxpullswagon), personal (e.g.,
bossdrivesbig truck, [dogs name]shakestoy, Iread
funny pages, Uncleboilsshrimp, [wifes name]sews
curtains), encyclopedic or world knowledge (e.g., judgereads
constitutional law book, hula dancershakeships, state
policeweightrucks, Benjamin Franklinflykite, funeral
directorbrusheshair, Mrs. Clintonwritesbiography), and
other (e.g., mad scientistboilhead of Frankenstein, vampires
bitehumans) topics. Thus, treatment on only 10 verbs resulted
in activation and production of a wide range of noun con-
cepts (not including responses to wh-questions).
These data highlight the extent of noun retrieval
in VNeST, where the semantics and phonology of noun
concepts are presumably strengthened. However, there is
relatively little production of the trained verb, and that
production occurs only after the verb is provided by the
clinician. Step 5 of the protocol was added to promote
independent verb retrieval. However, this task is not entirely
in the spirit of VNeST, which encourages truly independent
retrieval of concepts. Further, this step could be achieved
through recruitment of short-term memory. Given the
relative complexity of verb retrieval and the necessity for
verb retrieval to construct a sentence (Marshall et al., 1998),
more access to phonology (i.e., more production) of verbs in
VNeST may be warranted to maximize the potential for
generalization. Evidence for this is seen in the sentence probe
results, where verbs improved less robustly than the agents
and patients. Future studies will investigate integration of
more verb production into the protocol.
The improvements reported in the current and pre-
vious VNeST studies in (the reduction of) aphasia severity,
functional communication (by report), and lexical retrieval
and sentence production abilities from single words through
discourse are generally more robust than reports from
other verb treatment studies reported in the literature (see
Conroy et al., 2006; Webster & Whitworth, 2012). The
findings also suggest high potential clinical utility of VNeST.
We controlled treatment dosage to 35 hr per week over
10 weeks, consistent with a traditional aphasia treatment
plan and treated only 10 verbs per participant (fewer than
other verb treatments; e.g., Raymer & Ellsworth, 2002;
Wambaugh &Ferguson, 2007; Webster, Morris, &Franklin,
2005), though personal and salient responses to verb prompts
were encouraged from participants to promote relevance
and interest. Treatment is also low-tech (only pen and paper
required) and as such is transportable and easily delivered
in multiple settings. In addition, VNeST adapts relatively
easily to computer and telepractice use (Furnas & Edmonds,
2014), providing clinicians and participants with more
potential opportunities for home treatment and practice.
Thus, VNeST is easy to administer and potentially efficient,
and it offers high potential gains.
Though more research is needed to better define par-
ticipant characteristics, results across VNeST studies sug-
gest that participants with moderatesevere to mild aphasia
may be potential candidates. We have not conducted a
detailed analysis of outcomes based on aphasia types. How-
ever, on the basis of our observations, persons with nonfluent,
even agrammatic, aphasia show gains to lexical retrieval
of content words in sentence production with mixed im-
provement to discourse. Syntax (i.e., word order) in these
participants is typically well maintained. It should be noted
that none of the sentence probes are reversible. Because word
order is highly biased toward animate subjects, partici-
pants with potential syntax or mapping impairments may be
using animacy cues to aid production. Persons with fluent
aphasia tend to exhibit more efficient and informative
sentence production posttreatment, including reduced cir-
cumlocution and reduced use of general terms (e.g., guy,
lady) and pronouns. Discourse is also variable in these
participants. Finally, we used fairly permissible inclusion
criteria, to allow for relatively broad generalization of
results. This resulted in a mix of aphasia types, including only
one person with Wernickes aphasia. In future studies, we
will increase targeted recruitment and perform more detailed
testing to gain more insight into the effects of pretreatment
impairment patterns and aphasia types.
The development of aphasia treatment protocols can
involve many Phase 2 studies to narrowpotential candidates,
refine treatment and outcome measures, and estimate dos-
age (Robey, 2004). Three studies with VNeST have now
tested 17 participants, with overall positive results. However,
there are still limitations that need to be addressed in
addition to those we have already mentioned. First, we need
objective measures of functional communication in addition
to proxy report. Second, we need to evaluate the effects
of treating verbs with more diverse semantic and syntactic
representations, as only a small number of verbs and verb
types have been trained, largely because of the limitations of
the sentence probes (e.g., semantically related, imageable,
transitive verbs). The process of refining an aphasia treat-
ment protocol and understanding who might optimally
Edmonds et al.: Verb Network Strengthening Treatment S325
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benefit from it is a long process. However, we are committed
to that process in order to contribute evidence-based options
to clinicians who serve persons with aphasia.
Acknowledgments
This work was supported by the Department of Veterans
Affairs, Veterans Health Administration, Rehabilitation Research
and Development Grant 1I01RX000563-01 (to Lisa A. Edmonds).
We acknowledge the research participants and their families for
their enthusiasm and motivation throughout. We also extend our
thanks to the following collaborators, research assistants, and
clinicians in the Aphasia Lab at the Brain Rehabilitation and
Research Center at the Malcom Randall VA Medical Center and
Brooks Rehabilitation in Jacksonville, FL: Sam Wu, Jodi Morgan,
Ceil Brooks, Brayleah Kernan, Flo Singletary, and Carolyn
Hanson.
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Appendix (p. 1 of 2)
Verb Network Strengthening Treatment Materials and Protocol
Treatment Materials
Treatment stimuli consisted of the following:
1. 10 cards containing the names of the 10 trained verbs (Verb Set 1) (e.g., measure)
2. 68 cards for each verb containing 34 agents and 34 patients that form 34 pairs related to each verb (e.g., chefsugar,
carpenterlumber, surveyorland, and designerroom for the verb measure)
3. 5 cards containing the following words: who, what, where, when, why
4. An average of 25 sentences per verb to be used for semantic judgment.
These sentences spanned four categories: (a) correct (The designer measures the room), (b) inappropriate agent (The infant
measures the lumber), (c) inappropriate patient (The chef measures the television), and (d) thematic reversal (The room measures
the designer).
Treatment Protocol
Step 1: The clinician lays who and what cards on the table facing the participant and asks Who can/might verb something/
someone? (e.g., Who might drive something?). When the participant cannot produce an agent, he or she is given a semantic
or context cue (e.g., Who might drive for his/her job?). If that cue does not work, then four cards with possible choices are
provided, three cards with foils and one plausible option. The participant reads through the options one at a time (with assistance
from the clinician, if needed) and chooses the correct response. Once an agent is chosen, then a corresponding patient is
requested (e.g., If the participant said soldier, then the patient might be tank). Participants are encouraged to provide at least
one personal pair (e.g., dadboat for drive), and responses can change from week to week. (Previous VNeST studies requested
a list of agents or patients and then the corresponding noun, but it is more natural to generate one schema at a time.) In an
effort to promote more participant involvement during this step in the current study, the last six participants wrote their response
after they said it (rather than the clinician providing the written word). If they were incorrect about the spelling, they were given
the word to copy (and in the same way no phonemic cues or feedback was given, neither was there any writing feedback
[e.g., phoneme to grapheme correspondence]). Examination of probe results revealed no advantage or difference for participants
who wrote responses.
Step 2: The participant reads the triads aloud (e.g., cheffrytomatoes). Morphology or inflection is not required, but it is not
discouraged if participants use it (e.g., The chef is frying the tomatoes).
Step 3: The participant chooses one scenario (e.g., chef scenario) and answers three wh-questions about it (e.g., where?
[restaurant], when? [before restaurant opens], why? [to make them delicious]) about it. If the participant has difficulty
understanding the wh-questions, then clarification is given (e.g., Where? What location or place?) See Figure A1.
Step 4: The participant decides whether semantic judgment sentences (12 total, 3 from each category) are correct or not.
The four categories are (a) correct (The designer measures the room), (b) inappropriate agent (The infant measures the lumber),
(c) inappropriate patient (The chef measures the television), and (d) thematic reversal (The room measures the designer).
Step 5: The participant is asked what verb or action he or she has been working on. This step was added to allow one
opportunity for independent verb retrieval.
Step 6: Step 1 is repeated, but no cues are given, and the step is terminated when the participant retrieves three to four pairs
or when the participant cannot generate any more pairs, whichever occurs first.
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Appendix (p. 2 of 2)
Verb Network Strengthening Treatment Materials and Protocol
Figure A1. Example of card layout for VNeST steps 1 and 3.
Edmonds et al.: Verb Network Strengthening Treatment S329
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