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Audiological Assessment of Word Recognition Skills in Persons With Aphasia

Article  in  American Journal of Audiology · December 2017

DOI: 10.1044/2017_AJA-17-0041

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 AJA
Clinical Focus
Audiological Assessment of Word Recognition
Skills in Persons With Aphasia
Min Zhang,a,b Sheila R. Pratt,a,b Patrick J. Doyle,a,b Malcolm R. McNeil,a,b
John D. Durrant,a,b Jillyn Roxberg,a and Amanda Ortmanna,b
Purpose: The purpose of this study was to evaluate the
ability of persons with aphasia, with and without hearing
loss, to complete a commonly used open-set word
recognition test that requires a verbal response. Furthermore,
phonotactic probabilities and neighborhood densities of
word recognition errors were assessed to explore potential
underlying linguistic complexities that might differentially
influence performance among groups.
Method: Four groups of adult participants were tested:
participants with no brain injury with normal hearing, participants
with no brain injury with hearing loss, participants with brain
injury with aphasia and normal hearing, and participants with
brain injury with aphasia and hearing loss. The Northwestern
University Auditory Test No. 6 (NU-6; Tillman & Carhart, 1966)
was administered. Those participants who were unable to
respond orally (repeating words as heard) were assessed
with the Picture Identification Task (Wilson & Antablin, 1980),
permitting a picture-pointing response instead. Error patterns
from the NU-6 were assessed to determine whether
phonotactic probability influenced performance.
A
common impression among audiologists is that
persons with aphasia (PWA) and other neuro-
genic communication disorders make up a limited
portion of the clinical census but require extra time and
special adjustments in order to complete a standard audio-
metric test battery (Palmer, Adams, Durrant, Bourgeois, &
Rossi, 1998; Wilson, Shanks, & Flowler, 1981). However,
little has been published to support this impression. The
a
Geriatric Research, Education, and Clinical Center, VA Pittsburgh
Healthcare System, PA
b
Department of Communication Science and Disorders, University of
Pittsburgh, PA
Correspondence to Sheila R. Pratt: spratt@pitt.edu
Jillyn Roxberg is now at the University of Pittsburgh Medical
Center, PA.
Amanda J. Ortmann is now at Washington University, St. Louis, MO.
Editor-in-Chief: Sumitrajit Dhar
Editor: Lauren Calandruccio
Received April 17, 2017
Revision received June 23, 2017
Accepted August 1, 2017
https://doi.org/10.1044/2017_AJA-17-0041
American Journal of Audiology • 1–18 • Copyright © 2017 American Speech-Language-Hearing Association
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Results: All participants with no brain injury and 72.7%
of the participants with aphasia (24 out of 33) completed
the NU-6. Furthermore, all participants who were unable
to complete the NU-6 were able to complete the Picture
Identification Task. There were significant group differences
on NU-6 performance. The 2 groups with normal hearing
had significantly higher scores than the 2 groups with
hearing loss, but the 2 groups with normal hearing and
the 2 groups with hearing loss did not differ from one
another, implying that their performance was largely
determined by hearing loss rather than by brain injury or
aphasia. The neighborhood density, but not phonotactic
probabilities, of the participants’ errors differed across
groups with and without aphasia.
Conclusions: Because the vast majority of the participants
with aphasia examined could be tested readily using an
instrument such as the NU-6, clinicians should not be
reticent to use this test if patients are able to repeat single
words, but routine use of alternative tests is encouraged for
populations of people with brain injuries.
notion that PWA and other neurogenic communication
disorders are difficult to test does raise the concern about
appropriate service delivery for these patients and whether
they have reduced likelihood of referral for audiological
assessments and rehabilitation services, such as hearing
aids, auditory training, and counseling. This is a substan-
tive issue because the epidemiological data on hearing loss
and neurogenic communication disorders suggest that both
disorders become more common in early middle age, with
rates accelerating with increasing age (Agrawal, Platz, &
Niparko, 2008; Chapman & Ulatowska, 1992). As the
mean age of the population in the United States continues
to rise, so too will the occurrence of age-related comorbid
conditions.
Neurogenic Communication Disorders
It is estimated that 20% of the population with speech
and language impairment are over 65, and the majority of
these individuals have neurogenic disorders (Fein, 1983).
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
1
 Stroke is a common cause of neurogenic communication
disorders in adults, with 60% of noncomatose stroke sufferers
exhibiting some type of speech and language impairment
(Robins & Weinfeld, 1981). The age-adjusted prevalence of
stroke among adults in the United States is estimated at 2.6%
(Fang, Shaw, & George, 2017; Neyer et al., 2007), with
incidence estimated as 26% (Code & Petheram, 2011). There
is a substantive rise in stroke in the 40- to 50-year age range,
and with advancing age, the risk of stroke accelerates as
does the risk of aphasia (Bonita, Solomon, & Broad, 1997;
Engelter et al., 2006; Fang et al., 2017). An estimated 35% of
stroke patients will leave the hospital with aphasia (Dickey
et al., 2010; Flowers, Silver, Fang, Rochon, & Martino,
2013), and of those patients with aphasic symptoms at
discharge, two thirds will continue to have symptoms after
12 months (Kauhanen et al., 2000). Other types of brain
injury also cause aphasia. For example, about one third
of patients with closed head injury exhibit aphasia (Luzzatti,
Willmes, Taricco, Colombo, & Chiesa, 1989), and some
forms of frontotemporal degenerative disease result in pro-
gressive aphasia independent of more general cognitive
decline (Duffy & McNeil, 2008).
Prevalence of Hearing Loss
A growing number of studies have shown that hearing
loss is strongly related to age, with only detailed underlying
causes subject to debate. Cruickshanks et al. (1998) assessed
3,556 adults from Beaver Dam, Wisconsin, and found
the prevalence of hearing loss to be 21% in adults ages 48–
59 years, 44% for ages 60–69 years, 66% for ages 70–79 years,
and 90% for ages 80–92 years. The Keokuk County Rural
Health Study revealed similar results in a group of 1,975
adults (Flamme et al., 2005). An estimated 3.1% of adults
aged 20–29 years have a hearing loss, and 49% of adults
aged 60–69 years have a hearing loss specific to the 500- to
2000-Hz speech frequency range (Agrawal et al., 2008). Men
are more likely to have hearing loss and at greater severity
than women (Gates, Cooper, Kannel, & Miller, 1990; Helzner
et al., 2005; Pratt et al., 2009), and hearing loss varies in
prevalence and severity by race and ethnicity (Helzner et al.,
2005; Pratt et al., 2009), which interact in complex ways with
cardiovascular disease and aging. Self-perceived hearing im-
pairment and handicap increase with age but underestimate
the measured prevalence of hearing loss. Desai, Pratt, Lentzner,
and Robinson (2001), Wallhagen, Strawbridge, Cohen, and
Kaplan (1997), and Pratt et al. (2009) found that only about
30% of the population perceived themselves as being hearing
impaired by the age of 70 years, and by 80 years, only 50%
reported being hearing impaired, yet by 80 years nearly
90% have some hearing loss as measured by pure-tone thresh-
old testing.
Assessing Hearing in PWA
When assessing the hearing of patients who have
aphasia, pure-tone threshold testing can be completed with
little or no procedural modifications (Formby, Phillips, &
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Thomas, 1987; Rankin, Newton, Parker, & Bruce, 2014;
Wilson et al., 1981). However, persons with speech, lan-
guage, and cognitive impairments resulting from brain
injury can present challenges for speech recognition testing.
Verbal repetition of single syllables or monosyllabic words
is a common test method for assessing speech recognition
in clinical settings, so modifications might be necessary
to accommodate individuals with brain injury who have
difficulty in responding verbally due to speech and/or lan-
guage production impairments. Written responses or mark-
ing responses on a paper form or computer screen usually
require the ability to read and write or use a keyboard or
pointing device. These response requirements can be difficult
for some PWA. Yet, many of these alternative test methods
employ a closed-set rather than the more typical open-set
approach, which can reduce linguistic and cognitive loads.
Requiring a picture-pointing response and using a limited
set-size often can reduce response demands and increase
the likelihood of successful testing with this population.
Speech recognition testing is useful when assessing the
hearing of PWA in an effort to separate the effects of periph-
eral hearing loss from the impact of the brain injury on
language (Wilson et al., 1981). The need to disentangle
peripheral hearing loss from central processing problems
can be a critical issue for PWA, who by definition have
auditory language-processing difficulties (McNeil & Pratt,
2001). Standard of care in audiology dictates that minimally
basic pure-tone and speech audiometry should be com-
pleted. Moreover, for other applications (e.g., differential
diagnostic testing and hearing aid fitting/troubleshooting),
speech recognition remains a valuable benchmark of the
patient’s auditory capacity. Thus, any reluctance of clini-
cians to test PWA beyond basic pure-tone audiometry is
unwarranted.
The presence of aphasia also increases the need for
the comprehensive assessment of hearing abilities, because
hearing directly impacts the diagnosis and treatment of
aphasia. There are a number of tests sensitive to the pres-
ence of aphasia, for example, Porch Index of Communica-
tive Ability (PICA; Porch, 1973, 1981) and Computerized
Revised Token Test (CRTT; McNeil et al., 2015), but
performance on many tests of aphasia can be impacted
adversely by hearing loss. A person with a hearing loss might
be unresponsive or respond inappropriately if they are
unable to hear instructions clearly and subsequently mis-
perceive test items. As a result, hearing loss increases the
risk of invalid and unreliable results, misdiagnoses, and
elevated estimates of aphasia severity.
Speech Perception and Aphasia
The initial stages of speech perception, including
signal detection, discrimination, and identification, are
critical to the auditory language comprehension process—
a process that is tightly coupled to other sensory modalities
and higher-level processes (McNeil et al., 2015). By defini-
tion, aphasia is a multimodality inefficiency in the cogni-
tive processes that support language access, manipulation,
 and representation building (e.g., association, storage, re-
trieval, and rule implementation; McNeil, Odell, & Campbell,
1982; McNeil & Pratt, 2001; Neyer et al., 2007). Substantial
research has been conducted to investigate whether the
language disorders of PWA can be attributable to the per-
ception of lower-level (acoustic/phonetic) speech character-
istics. Though acoustic/phonetic deficits are observed in
PWA, their deficits do not account for the magnitude of
their language comprehension and production problems.
For example, Blumstein et al. (2000) studied the ability of
PWA to discriminate and identify consonant–vowel syllables
and compared speech perception results to auditory language
comprehension as assessed with standard aphasia diag-
nostic tests. They found that the magnitude of the speech
perception deficits did not correspond well with the sever-
ity of their participants’ auditory language comprehen-
sion problems, especially in persons classified as having
Wernicke’s aphasia. A study conducted by Baker, Blumstein,
and Goodglass (1981) used a word-to-picture matching
task with persons with Wernicke’s aphasia. Overall, the par-
ticipants demonstrated more than 80% accuracy, but some
did make phonemic and semantic errors. Similarly, persons
with transcortical sensory aphasia, which also is associated
with substantial auditory language comprehension deficits,
demonstrated intact phonemic perception processes and the
ability to repeat speech stimuli (Luzzatti et al., 1989). Simi-
larly, Hickok, Costanzo, Capasso, and Miceli (2011) studied
a large group of patients classified as having Broca’s aphasia
and found syllable discrimination and single-word recogni-
tion performance to be near ceiling and largely unrelated
to verbal fluency. In contrast, Caplan, Gow, and Makris
(1995) reported on a group of PWA who demonstrated par-
ticular deficits in phoneme discrimination at the syllable
level. This group was considered atypical but did suggest
the need to be sensitive to the performance variability that
can be observed across PWA.
Speech perception deficits at the acoustic/phonetic level
in PWA tend to be task and stimuli dependent (Blumstein,
1994, 2009; Hickok & Poeppel, 2000). Persons with aphasia
are usually able to discriminate pairs of stimuli but have more
difficulty with identification tasks that require a label or the
association of speech sounds with a label (Hessler, Jonkers, &
Bastiaanse, 2010). As with adults without brain injury, the
use of real words facilitates performance in PWA, but the
use of real words adds additional layers of complexity asso-
ciated with lexical/semantic processing. The problems en-
countered by PWA on auditory word recognition tasks
have largely been attributed to difficulties with lexical access
and activation and not necessarily the perception and map-
ping of acoustic/phonetic cues onto the lexicon (Blumstein,
Milberg, & Shrier, 1982; Milberg & Blumstein, 1981). Many
PWA can discriminate and recognize isolated syllables and
single words with limited difficulty, but they experience
difficulty when they have to act on the speech signals at
more complex linguistic and cognitive levels. There also is
evidence that PWA vary in their sensitivity to acoustic per-
turbations, as evidenced in auditory semantic priming and
eye-tracking tasks, which could mean that the impact of
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hearing loss on lexical processing also could vary substan-
tively (Aydelott & Bates, 2004; Kittredge, Davis, & Blumstein,
2006; Milberg, Blumstein, & Dworetzky, 1988; Mirman,
Yee, Blumstein, & Magnuson, 2011; Misiurski, Blumstein,
Rissman, & Berman, 2005).
The repetition of words during clinical speech rec-
ognition testing requires sound detection, sublexical pro-
cessing, and a motor response. So, if PWA can repeat
words accurately, it is assumed that their motor control
for speech/language production is sufficient for the task
and their auditory language deficits can be relegated to the
postacoustic/phonetic levels of processing. Comprehension
of the words should facilitate their performance but is
not required to complete the task. Variables such as word
length, frequency, and neighborhood density can impact
the accuracy and reaction time of their responses, but the
ability to repeat single words usually is not eliminated by
these variables in many PWA. Thus, a majority of PWA
should be able to complete common clinical speech recog-
nition tasks, which in turn allows for the elimination of
low-level auditory processing deficits as a factor that might
exacerbate or be confused with difficulties with language.
Moreover, when PWA are unable to repeat words in a
speech recognition task, using a test that requires a point-
ing response might serve as a successful alternative if the
limitation is not at the perceptual acoustic/phonetic level
of processing. That is, if deficits at the phonological output
or speech movement level of the system limit response
accuracy, then a picture-pointing response could serve as
an alternative response mode.
Phonotactic Probability and Neighborhood Density
The primary aim of this study was to obtain informa-
tion about the ability of PWA to complete traditional speech
recognition testing as found within an audiology clinical
context. An additional goal was to examine the errors pro-
duced by PWA (with and without hearing loss) by looking
at the phonotactic probability and phoneme neighborhood
density of their errors in order to explore the potential under-
lying linguistic complexities that might differentially influ-
ence performance among groups. In auditory studies, these
psycholinguistic variables have been used to assess the impact
of stimulus characteristics on perceptual performance, but
in speech and language research, it is common to use phono-
tactic probabilities and neighborhood density to examine
production characteristics. The hypothesis in the current
study was that the error patterns would provide insight into
the overall output difficulties encountered due to the motoric
and linguistic complexity of the stimuli.
Phonotactic probability refers to the frequency with
which phonological segments and sequences occur in words
in a given language (Jusczyk, Luce, & Charles, 1994) and
is frequently determined through analysis of a word corpus
(e.g., dictionary). There is evidence that phonotactic proba-
bility influences language processes (Gaygen, 1997; Pitt &
McQueen, 1998) and how quickly adults with normal hear-
ing and adults with hearing loss recognize spoken words
3
 (Vitevitch, Pisoni, Kirk, Hay-McCutcheon, & Yount,
2002). Phonotactic probability also impacts how rapidly
and accurately adults with normal hearing repeat real words
and nonwords (Vitevitch & Luce, 2005). Neighborhood
density refers to the number of phonologically similar words
within a certain corpus. Dirks, Takayana, and Moshfegh
(2001) examined lexically easy (high word frequency with
low neighborhood density) versus difficult word (low word
frequency with high neighborhood density) recognition in
listeners with normal and impaired hearing. They found
that neighborhood structure influenced the relative perfor-
mance of persons with hearing loss in the same manner as
persons with normal hearing, with both groups performing
better on lexically easy than hard words. However, the
results have not been consistent across studies. For example,
a facilitative effect of neighborhood density was found in
some studies (Luce & Pisoni, 1998; Vitevitch & Luce, 1998),
but competitive effects were found in others (Byrne & Dillon,
1986; Dickey et al., 2010). Results of some studies have
revealed neighborhood density and phonotactic probability
effects in people with aphasia. In a cross-linguistic study,
Lallini, Miller, and Howard (2007) showed that the number
of phonemes and clusters in target words was the major
predictors of repetition accuracy but found no phonotactic
probability or neighborhood density effects. These results
are consistent with Nickels and Howard (2004), who manip-
ulated the number of phonemes, syllables, and consonant
clusters. They observed an effect of phoneme number on
word production accuracy in English and proposed that
the potential source of phonological production errors
produced by PWA is at the phonemic level, although an
alternative explanation is that performance is impacted
by reduced speech motor abilities. Gordon (2002) investi-
gated the role of phonological neighborhood density in a
study of production errors by PWA. She found that neighbor-
hood density exerted a facilitative effect at the sublexical
level. The pattern of word retrieval and production in
PWA was similar to that found in the speech of neuro-
logically healthy adults (Vitevitch, 2002).
Of interest in the current study was whether listeners
with aphasia and/or hearing loss produced errors during
speech recognition testing that consisted of more common
sound combinations (high phonotactic probability) and
denser neighborhoods, or rarer structures (low phonotactic
probability) and sparser neighborhoods than was found in
the target words. That is, was lexical difficulty a response
factor in the participants who had aphasia?
Purpose
This study examined whether a commonly used word
recognition test, the Northwestern University Auditory
Test No. 6 (NU-6; Tillman & Carhart, 1966), could be
administered successfully to PWA and whether their perfor-
mance differed by hearing status and from that of neuro-
logically healthy listeners. In addition, if unable to perform
the NU-6, could an alternate/nonverbal response word rec-
ognition test (Picture Identification Task [PIT]) be used
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confidently in PWA to assess word recognition? The study
also examined whether the types of errors produced during
testing differed in terms of phonotactic probability and
neighborhood density as a function of hearing status and
presence of aphasia.
Method
Participants
A total of 105 adults participated in this experiment:
adults with no brain injury with normal hearing (NBI-NH;
n = 30), adults with no brain injury with hearing loss (NBI-HL;
n = 42), PWA with normal hearing (PWA-NH; n = 25),
and PWA with hearing loss (PWA-HL; n = 8). They were
recruited through flyers, advertisements, clinicians in the
VA Pittsburgh Healthcare System, the VA Pittsburgh Health-
care System Aphasia Registry, as well as clinicians in the
community. The study was approved by the VA Pittsburgh
Healthcare System Internal Review Board, and the partici-
pants provided oral and written informed consent prior to
participating in the study. All participants received remuner-
ation for their participation and were reimbursed for travel
expenses.
The study was limited to adults between the ages of
30 and 90 years, with and without clinically significant
hearing loss and with and without brain injury with aphasia.
The participants with hearing loss were required to have
a symmetrical, bilateral, postlingual sensorineural hearing
loss that was moderate to severe in severity and pre-
dominately high frequency in configuration. They also
were required to have consistently worn hearing aids in both
ears for at least 1 month so that they were familiar with
listening to amplified sound and sufficiently comfortable
with their hearing aids to wear them during some of the
preliminary testing (e.g., aphasia testing). The PWA needed
to have a documented left hemisphere lesion and meet the
definition of aphasia (McNeil & Pratt, 2001) as evidenced
by their performance on the PICA (Porch, 1981). The
PICA was selected for this investigation because it pro-
vides greater sensitivity to deficits than other aphasia tests
due to its 16-point multidimensional scoring system. The
construction of the test also allows more transparent inter-
pretation of performance than other tests of aphasia because
of the homogeneity of test items used across subtests and
the extensive psychometric development of the test. To
prevent inclusion of PWA with very mild and very severe
aphasia, the participants with aphasia were required to per-
form between the 5th and 95th percentiles for PWA. Also,
none of the PWA showed any deficit patterns consistent
with central deafness, which, it should be noted, is extremely
rare (Leicester, 1980; Musiek & Lee, 1998).
The NBI-NH participants (12 women, 18 men)
ranged in age from 42 to 81 years (M = 62), the NBI-HL
participants (15 women, 27 men) ranged in age from 40
to 86 years (M = 67), the PWA-NH (13 women, 12 men)
ranged in age from 38 to 82 years (M = 56.56), and the
PWA-HL (1 woman, 7 men) ranged in age from 65 to
 Table 1. Mean pure-tone average and age of participants.
88 years (M = 77.25). Although efforts were made to balance
age across groups, the PWA-HL group was somewhat
HFPTA (dB HL) Age (years)
older than the other three groups, largely due to the limited
number of available participants with aphasia in the com- Group M SD M SD
munity who had a hearing loss and also wore hearing aids.
Most people with aphasia and hearing loss were not aided, NBI-NH 15.27 6.89 62.03 9.61
NBI-HL 52.35 12.16 67.02 11.18
unless they had been fitted prior to their brain injury (Läßig, PWA-NH 15.44 6.33 56.56 11.36
Kreter, Nospes, & Keilmann, 2013). However, an effort PWA-HL 53.88 13.65 77.25 6.61
was made to balance average hearing thresholds across the
two groups with hearing loss and between the two groups Note. HFPTA = high-frequency pure-tone average for thresholds
obtained at 1000, 2000, and 4000 Hz; NBI-NH = individuals with no
with normal hearing (see Figure 1 and Table 1). brain injury with normal hearing; NBI-HL = individuals with no brain
injury with hearing loss; PWA-NH = persons with aphasia with normal
hearing; PWA-HL = persons with aphasia with hearing loss.
Procedure
Preliminary Tests
Preliminary testing was conducted to document eligi- with a clinical audiometer (GSI 16), and the tympanometry
bility, hearing loss, and aphasia severity. A routine audio- and reflex screening was completed in a quiet room with a
metric exam was conducted that consisted of pure-tone diagnostic acoustic admittance system (GSI TympStar). Dis-
threshold testing (American Speech-Language-Hearing tortion product otoacoustic emissions for octave frequencies
Association [ASHA], 2005), speech recognition threshold also were assessed to help confirm cochlear hearing status.
testing (ASHA, 1979), assessment of middle ear function that In addition to the standard audiometric testing, electro-
consisted of a 226-Hz screening tympanogram, and a 1000-Hz physiological testing of the auditory system was performed
acoustic reflex screen. The pure-tone and speech recognition with a clinical evoked potential system (Intelligent Hearing
threshold testing was conducted in a sound-attenuated booth System, SmartEP). Auditory brainstem response and middle

Figure 1. Average audiometric threshold for each group. Error bars indicate ±1 SD. PWA-NH = persons with aphasia with normal hearing;
PWA-HL = persons with aphasia with hearing loss; NBI-NH = individuals with no brain injury with normal hearing; NBI-HL = individuals with
no brain injury with hearing loss.

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 Table 2. Group performance on the PICA and CRTT.
Overall PICA Verbal PICA
Groups M SD M SD
NBI-NH 14.05 0.43 14.40 0.39
NBI-HL 13.95 0.39 14.27 0.37
PWA-NH 12.32 1.13 11.81 2.92
PWA-HL 12.30 1.49 12.03 3.16
Note. PICA = Porch Index of Communicative Ability; CRTT = Computerized Revised Token Test; NBI-NH =
individuals with no brain injury with normal hearing; NBI-HL = individuals with no brain injury with hearing loss;
PWA-NH = persons with aphasia with normal hearing; PWA-HL = persons with aphasia with hearing loss.
latency response testing was completed with click stimuli
presented at 90 dB nHL and the N1-P2 (slow vertex poten-
tial with 500 Hz tone bursts presented at 50 dB HL). These
potentials were evoked to assess the integrity of the auditory
pathway and primary auditory cortices. The stimuli and
presentation levels were selected to ensure audibility across
all participants. All electrical recordings were made from
an electrode at vertex referenced to the mastoids bilaterally
(two-channel recording for auditory brainstem response
and middle latency response; single-channel with tied mas-
toids for N1-P2). Waves V, Pa, N1, and P2 latencies and
amplitudes were measured. The results were compared with
local age-corrected and hearing loss–corrected norms and
needed to be within 3 SDs of the mean for participant inclu-
sion. Only one participant was excluded from the study
because of the electrophysiolocal testing, and he was later
diagnosed with a brain tumor. This participant would have
been in the NBI-NH group if included.
The PICA was administered to document the pres-
ence and profile of aphasia. The PICA includes four hier-
archical ordered subtests that contribute to the verbal PICA
score. These subtests were examined to determine whether
phonological output and speech motor control, rather than
language, explained the ability to complete the NU-6. Sub-
test XII requires the simple repetition of the word form,
which necessitates the engagement of the output phonology
and speech motor control systems. It does not require accu-
rate visual recognition of the simple objects used in the test
but does require sufficient auditory perceptual resolution to
encode the speech sounds from the acoustic stimulus. Further-
more, semantic, lexical, and phonological recall of the word
form is not required for correct performance. Therefore, Sub-
test XII (imitate/repeat the names of common objects) is the
least difficult of the verbal PICA subtests for most PWA.
In contrast, Subtest I requires sentence formulation after
accurate visual recognition of the test objects. Because all
levels of linguistic formulation (semantics, syntax, lexical,
and phonologic) and recall from long-term memory are
required for successful completion of this subtest, it is
usually the most difficult of the verbal PICA subtests. The
task requirements for the other two verbal subtests are more
intermediate in difficulty for typical PWA.
A 55-item version of the CRTT (McNeil et al., 2015)
that mirrored the noncomputerized 55-item Revised Token
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Auditory PICA Overall CRTT
M SD M SD
14.99 0.03 14.60 0.32
14.95 0.10 14.55 0.29
14.45 0.80 12.79 1.55
14.08 0.88 12.24 1.83
Test (Arvedson, McNeil, & West, 1985) was administered
to assess sentence-level auditory language processing. It
was administered multiple times across a range of intensity
levels, but only their asymptotic performance was used in
this analysis. Both tests of aphasia were completed in a
sound-attenuated booth by licensed and ASHA-certified
speech-language pathologists and audiologists with previous
training and experience with the tests. Demographic data
and performance on the PICA and the overall mean CRTT
score are shown in Table 2.
Word Recognition Testing
The NU-6 recordings from the Department of Veterans
Affairs compact disc were used as stimuli and included a
female speaker (Department of Veterans Affairs, 1998).
The 50-item word lists were subdivided into half-lists of
25 words, which is a common clinical practice and has been
validated for the NU-6 in previous studies (Dubno, Lee, Klein,
Matthews, & Lam, 1995). For this study, each ear was tested
separately with one of four half-lists (1A, 1B, 2A, 2B). The
recordings were played from a compact disc recorder/player
(Denon DN-T645) and routed through a clinical audiom-
eter (GSI 61) and presented via insert earphones (ER-3)
at 40 dB SL (re: three-frequency pure-tone average). If
performance was lower than expected (below the lower
95% confidence interval, as established by Dubno et al.,
1995), the test was readministered at 50 dB SL using a dif-
ferent half-list. No presentation level exceeded a participant’s
uncomfortable loudness level. If performance improved
and was within the 95% confidence intervals established by
Dubno et al. (1995), the results obtained at the elevated
level were used in the analyses; otherwise, the initial test
results were used. The participants who were slow to respond
or appeared to struggle with verbal responses were allowed
extra time by pausing the recording between words. The
duration and number of pauses were not recorded. The par-
ticipants were instructed to repeat the words that they heard
as clearly as possible, and the experimenter recorded errors
with broad phonetic transcription. Word recognition was
assessed with stimuli from the PIT (Wilson & Antablin,
1980, 1982) if a participant was unable to complete the NU-6
as evidenced by an inability to repeat the test stimuli after
reinstruction and face-to-face practice with the examiner,
or if the participant communicated that they were unable to
 perform the task. The words from the PIT were presented
at the same level as the NU-6, but rather than repeating
the words, the participants responded by pointing to one
of four pictures. The PIT stimuli were not administered for
comparisons with the NU-6 but to confirm that these partici-
pants could recognize single-word stimuli and complete an
alternative test requiring a picture-pointing response.
Dependent Variables and Analyses
The ability to complete the NU-6 and percent cor-
rect performance on the NU-6 were calculated and com-
pared across groups using a chi-square test and analysis
of covariance with age as the covariable, respectively.
Preliminary analyses with paired sample t tests were con-
ducted to confirm the symmetry of pure-tone threshold
across ears in each experimental group. A 2 (ear) × 4 (group)
mixed analysis of variance (ANOVA) was then performed
on the NU-6 scores to determine whether the NU-6 scores
were symmetric across ears and which NU-6 score per
ear was appropriate to use for subsequent analyses. The
percentage data were first converted to rau as suggested by
Studebaker (1985). The rau is a simple linear transforma-
tion of the arcsine transform for percentage or proportion
data and produces values that are numerically close to
the original percentage values over most of the percentage
range, while retaining all of the desirable statistical properties
of the arcsine transform.
Because the ability to verbally recall and produce words
is required for standard administration of the NU-6, it was
necessary to address the verbal production and auditory
processing skills of the PWA. A one-way between-subjects
multivariate analysis of variance was applied to the aphasia
test results of the PWA (i.e., overall mean CRTT score
and average scores from the verbal and auditory portions
of the PICA). The results were examined relative to the
ability to complete the NU-6. To assess possible predictors
of the ability of PWA to complete the NU-6, a logistic
regression model was implemented with hearing status,
age, verbal PICA, auditory PICA, and overall mean CRTT
as predictor variables. An additional logistic regression
model was performed to predict ability to complete the
NU-6 by PICA Subtests I, IV, IX, and XII.
In addition, the phonotactic probabilities and neighbor-
hood density of both target NU-6 words and the errors
produced on the NU-6 by participants were calculated and
compared across groups. The phoneme probability (also
referred to as positional segment frequency) represents the
frequency with which a particular segment occurs in a certain
position within a word. The biphoneme probability (also
referred to as biphone frequency) is the segment-to-segment
co-occurrence probability of sounds within a word. For the
participants who completed the NU-6, response errors were
referenced to “Klattese” international phonetic alphabet
equivalents (computer-readable phonemic transcription)
and then entered into a web-based phonotactic probability
calculator (Vitevitch & Luce, 2004). Stress and syllabification
markers were not included and were not a concern in this
study, because all NU-6 words are monosyllabic with a
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consonant–vowel–consonant structure. Phonotactic prob-
ability estimates were derived from the approximately
20,000 words in the 1964 Merriam-Webster Pocket Dictio-
nary. In order to provide an estimate of probability, the
log values of the frequencies with which the words occurred
in English were summed and then divided by the total log
frequency of all the words in the dictionary that have a
segment in that position. Log values were used because they
better reflect the distribution of frequency of occurrence
and have a higher correlation with performance than do
raw frequency values (Balota, Pilotti, & Cortese, 2001).
Neighborhood density was calculated using a web-
based program called N-Watch (Davis, 2005). It computes
neighborhood size and related measures of orthographic
and phonological similarity. The program allows for simi-
larity statistics for vocabularies specified by the user (Davis,
2005). The default vocabulary for the N-Watch program
was selected by cross-checking the raw CELEX corpus
(consisting of approximately 17.9 million words) against
an electronic dictionary containing 65,031 words and then
excluding entries that occurred less than 0.34 per million
or words that were more than 10 letters long (or shorter than
two letters), because words of this length are not typically
used in most psycholinguistic experiments. The resulting
vocabulary is composed of 30,605 words. The program
calculates the neighborhood density by counting all the words
in the corpus that phonologically differ from the target word
by a one-sound substitution, addition, or deletion in any
word position (Davis, 2005). The dependent variables in the
phonotactic probability analyses were the average
 deviation
of the error from the target (i.e., Error Target #Errors ) on pho-
neme probability, biphoneme probability and neighborhood
density, and the count of errors out of four 25-item NU-6
lists (100 words).
Results
Ability to Complete the NU-6
One hundred percent of the participants in the
NBI-NH (30 out of 30) and NBI-HL groups (42 out of 42)
completed the NU-6. In contrast, 73 percent (19 out of
25 PWA-NH and 5 out of 8 PWA-HL) of PWA partici-
pants completed the NU-6. The proportion of individuals per
group who were able to complete the NU-6 differed signifi-
cantly, χ2(3) = 22.887, p = .0009. A post hoc comparison
with Bonferroni correction revealed that the NBI groups
had a significantly higher proportion of people who could
complete the NU-6 than did the PWA-NH, χ2(1) = 8.082,
p = .004, and PWA-HL, χ2(1) = 12.214, p = .0009. However,
there was no significant difference between the PWA-NH
and PWA-HL groups, χ2(1) = 0.557, p = .456, indicating
that the ability to complete the NU-6 relates to the presence
of brain injury and aphasia and not hearing loss when pro-
vided adequate audibility.
There were a total of nine PWA participants who
were unable to complete the NU-6, but they all were able
to complete the PIT (see Table 3). As shown in Figure 2,
7
 Table 3. Characteristics of individual participants who were unable to perform NU-6.

Subject Group Age Sex HFPTA (dB HL) Overall PICA Auditory PICA Verbal PICA CRTT PIT (% correct)

S304 PWA-HL 75 M 63 11.44 13.45 11.27 11.01 88

S306 PWA-HL 76 M 47 9.11 12.40 4.65 10.63 84
S313 PWA-HL 75 M 67 12.26 14.40 13.73 10.45 84
S413 PWA-NH 69 F 23 10.62 14.10 11.58 11.39 88
S415 PWA-NH 44 F 13 11.06 15.00 6.00 11.31 100
S416 PWA-NH 38 M 15 11.04 15.00 3.68 11.76 92
S422 PWA-NH 40 M 13 11.99 13.60 11.18 12.09 92
S427 PWA-NH 49 M 10 12.23 14.90 13.43 13.17 100
S433 PWA-NH 50 M 21 11.97 13.40 10.70 11.50 88

Note. NU-6 = Northwestern University Auditory Test No. 6; HFPTA = high-frequency pure-tone average for thresholds obtained at 1000,
2000, and 4000 Hz; PICA = Porch Index of Communicative Ability; CRTT = Computerized Revised Token Test; PIT = Picture Identification
Task; PWA-NH = persons with aphasia with normal hearing; PWA-HL = persons with aphasia with hearing loss; M = male; F = female.

the PWA who were able to complete the NU-6 had signifi-
cantly higher overall PICA scores than those who were
unable to complete the test, Pillai’s trace = .260, F(3, 29) =
3.396, p = .031, ηp2 = .260. They also had significantly
higher verbal (oral language production) PICA scores than
those who were not able to complete the test (see Table 4),
F(1, 31) = 9.519, p = .004, ηp2 = .235. However, there was no
difference between these two groups on the auditory PICA
or overall mean CRTT score, F(1, 31) = 2.122, p = .155,
ηp2 = .064 and F(1, 31) = 0.002, p = .967, ηp2 < .001,
respectively.
The results of an all possible subsets model selection
analysis suggested the verbal PICA score was the best
predictor of the ability to complete the NU-6 among
hearing status, age, verbal PICA, auditory PICA, and
overall mean CRTT based on the Mallows’s Cp, Akaike
Information Criterion (AIC ), Schwarz Bayesian Criterion
(SBC ), and Cox-Snell residuals, all diagnostic measures of
model quality and fit. The verbal PICA was significantly
better than the other two test measures, χ2(1) = 7.362,
p = .007, Negelkerke R2 = .290. There was no significant
difference between observed and predicted group membership
as classified by the verbal PICA score, Hosmer-Lemeshow
χ2(9) = 12.250, p = .200, and the overall classification rate
was good with a receiver operating characteristic area of
0.801. A cutoff verbal PICA score of 11.64 (i.e., cutoff
probability value of .740) could be used for classification
with minimal false negative and false positive rate using
Youden’s index. Seventy percent of the PWA were correctly
classified: 75% for those able to complete the NU-6 and
55.6% for those unable to complete the NU-6.
A separate model selection analysis on the ability to
complete the NU-6, as predicted by PICA subtests, generated
four comparable predictive models according to the Mallows’s
Cp, AIC, SBC and Cox-Snell residuals. Subtests XII (imitate/
repeat the names of common objects) and IV (name common
objects) significantly predicted the ability to complete
the NU-6 (Model 1), χ2(2) = 10.173, p = .006, Negelkerke
R2 = .384. The ability to complete the NU-6 also was sig-
nificantly predicted by Subtests XII and IX (complete sen-
tences by saying the names of common objects; Model 2),
χ2(2) = 10.101, p = .006, Negelkerke R2 = .382, and by

Figure 2. Mean Porch Index of Communicative Ability (PICA) and overall mean Computerized Revised Token Test (CRTT) score for the
participants with aphasia who were able to perform the Northwestern University Auditory Test No. 6 (NU-6; solid black bars) and those
who were unable to perform the Picture Identification Task (PIT; gray bars). Error bars indicate ±1 SD. PWA NU-6 = persons with aphasia
who were able to complete the NU-6; PWA PIT = persons with aphasia who were only able to complete the PIT.

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 Table 4. The demographic PICA performance by the participants with aphasia who were able to and who were not able to complete the NU-6.
Ability to Overall verbal PICA Subtest I
complete
the NU-6 M SD M SD
Able 12.72 2.04 11.01 2.48
Unable 9.58 3.79 8.14 2.82
Note. NU-6 = Northwestern University Auditory Test No. 6; PICA = Porch Index of Communicative Ability.
Subtest XII and Subtest I (describe the function of common
objects; Model 3), χ2(2) = 9.665, p = .008, Negelkerke R2 =
.368. In a fourth model, Subtest XII alone was a significant
predictor of the ability to complete the NU-6, χ2(1) =
9.635, p = .002, Negelkerke R2 = .367. Given Model 4, each
unit increase in Subtest XII score increased the likelihood
of being able to complete the NU-6 by 66%, B = 0.505, exp
(B) = 1.657, χ2(1) = 4.655, p = .003. Model comparisons indi-
cated that Subtest XII was the major contributor because
none of the other three subtests significantly predicted the
ability to complete the NU-6 after adjusting for the Sub-
test XII performance. However, Subtest XII alone was not
adequate for classification, because there was a significant
difference between observed and predicted group member-
ship, Hosmer-Lemeshow χ2(6) = 12.78, p = .047. The combi-
nation of Subtest XII and Subtest I (Model 3) classified
the best among the competing models, Hosmer-Lemeshow
χ2(6) = 7.04, p = .633, and the overall classification rate
was good with a receiver operating characteristic area of
0.838 (see Figure 3). A cutoff probability value of .744 was
used to minimize both false negative and positive rate using
Figure 3. The receiver operating characteristic curves for the verbal
Porch Index of Communicative Ability (PICA) score and two verbal
PICA subtest scores (Subtests I and XII) predicting the ability to
complete the Northwestern University Auditory Test No. 6. AUC =
area under the curve.
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Subtest IV Subtest IX Subtest XII
M SD M SD M SD
12.83 2.54 12.71 2.57 14.32 1.32
9.84 4.27 9.51 4.13 10.81 4.22
Youden’s index. With this cutoff, 82% of the participants
were correctly classified (87.5% were able to complete the
NU-6; 66.7% were unable to complete the NU-6).
The nine PWA who completed the PIT as an alterna-
tive speech recognition test produced scores ranging from
84% to 100% correct. The participants in the PWA-NH
group had higher scores (M = 93.33, SD = 5.47) than those
in the PWA-HL group (M = 85.33, SD = 5.47), but statisti-
cal comparisons were not performed due to the small sample
size. Because the equivalence between the NU-6 score and
the PIT score has not been documented in a quantitative
way, no comparison was conducted between the two tests.
Performance on the NU-6
The symmetry of the pure-tone thresholds between
ears was confirmed. There were no significant differences
on pure-tone average (average of thresholds for 500, 1000,
2000, and 4000 Hz) between ears for any of the groups:
NBI-NH, t(29) = −0.356, p = .725; NBI-HL, t(41) = 0.779,
p = .440; PWA-NH groups, t(24) = 0.706, p = .487; or
PWA-HL, t(7) = 1.330, p = .225. Despite symmetrical
pure-tone averages, some participants demonstrated minor
ear differences on the NU-6. Thirty-one participants had
identical NU-6 scores for both ears. Of the remaining par-
ticipants, performance differences between ears ranged
from 4% to 16%, which corresponded to one to four test
items in error. The magnitude of the ear differences on the
NU-6 was significant for groups (see Figure 4), F(3, 101) =
7.857, p = .0009, ηp2 = .189, and found for all four groups:
NBI-NH, F(1, 101) = 20.712, p = .0009; NBI-HL, F(1, 101) =
43.362, p = .0009; PWA-HL, F(1, 101) = 3.660, p = .008;
and PWA-NH, F(1, 101) = 4.879, p = .0009. Although rela-
tively small, subsequent analyses of the NU-6 scores were
based on the performance of the better ear because of the
significant ear differences.
For those participants who completed the NU-6, a
multiple regression analysis was conducted to determine
whether age and verbal PICA, auditory PICA, overall
PICA, and overall mean CRTT score significantly predicted
NU-6 performance (in rau) and should be considered as
covariates in the analysis. The regression was significant,
F(5, 90) = 4.552, p = .001, adjusted R2 = .157, and the
results showed a significant negative prediction of NU-6
rau score by age, B = −0.751, F(1, 90) = 21.520, p = .0009,
ηp2 = .193. However, no significant prediction of the NU-6
performance was found for the other factors, including
verbal PICA scores, B = 5.090, F(1, 90) = 2.519, p = .116,
Zhang et al.: Word Recognition Testing of Persons With Aphasia 9
 Figure 4. The mean Northwestern University Auditory Test No. 6 (NU-6) score for the better and worse
ears across groups. Error bars indicate ±1 SD. PWA-NH = persons with aphasia with normal hearing;
PWA-HL = persons with aphasia with hearing loss; NBI-NH = individuals with no brain injury with normal
hearing; NBI-HL = individuals with no brain injury with hearing loss.

ηp2 = .027 (see Figures 5 and 6). Hence, age was used as a
covariate in the following group comparisons.
A one-way between-subjects analysis of covariance was
performed on the NU-6 rau scores as a function of group
after adjusting for age. The homogeneity of regression assump-
tion was met, F(3, 88) = 0.937, p = .426, ηp2 = .031, as
were all other assumptions for the following analyses. After
removing the variance due to differences in age, a significant
group effect was observed, F(3, 91) = 16.772, p = .0009,
ηp2 = .356. As expected, the NBI-NH group (M = 106.326,
SE = 2.569) had significantly higher scores than the NBI-HL
(M = 84.100, SE = 2.180), F(1, 91) = 42.617, p = .0009,

Figure 5. The relationship between age and the Northwestern University Auditory Test No. 6 (NU-6) score (in rau).
Regression analysis indicated a significant correlation at p < .05. PWA-NH = persons with aphasia with
normal hearing; PWA-HL = persons with aphasia with hearing loss; NBI-NH = individuals with no brain injury
with normal hearing; NBI-HL = individuals with no brain injury with hearing loss.

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 Figure 6. The relationship between the verbal Porch Index of Communicative Ability (PICA) score and the
Northwestern University Auditory Test No. 6 (NU-6) score (in rau). The ability of the verbal PICA score to predict
the transformed NU-6 score was not significant at p < .05.

ηp2 = .319, and PWA-HL (M = 77.712, SE = 6.529),
F(1, 91) = 16.196, p = .0009, ηp2 = .151. Similarly, the
PWA-NH (M = 101.282, SE = 3.284) had significantly
higher scores than the NBI-HL group, F(1, 91) = 18.382,
p = .0009, ηp2 = .168, and PWA-HL group, F(1, 91) = 9.869,
p = .002, ηp2 = .098. However, the two groups with normal
hearing did not differ from each other, F(1, 91) = 1.508,
p = .223, ηp2 = .016, nor did the groups with hearing loss,
F(1, 91) = 0.887, p = .349, ηp2 = .010. Word recognition
performance for each group is illustrated in Figure 7.
Phonotactic Probabilities and Neighborhood
Density of Error Productions
n = 4), including combined information from both ears
tested separately, because no significant differences were
observed between ears on any of the phonotactic and neigh-
borhood measures: average phoneme probability, F(1, 64) =
2.511, p = .118, ηp2 = .036; average biphoneme probability,
Figure 7. The Northwestern University Auditory Test No. 6 (NU-6)
word recognition performance by group after adjusting for age. The
results are expressed in rau. Covariates appearing in the model
were evaluated at age = 63.89. Error bars indicate ±1 SE. PWA-NH =
persons with aphasia with normal hearing; PWA-HL = persons with
aphasia with hearing loss; NBI-NH = individuals with no brain injury
with normal hearing; NBI-HL = individuals with no brain injury with
hearing loss.

Prior to analyzing the error productions, the average

phoneme probability, biphoneme probability, and neighbor-
hood density of each target word in the four 25-word NU-6
lists were initially calculated. A one-way ANOVA was
performed to determine whether there were significant
differences in phonotactic probabilities and neighborhood
density across the four lists (see Figure 8). No differences
were found for biphoneme probability, F(3, 96) = 0.885,
p = .452, ηp2 = .027, phoneme probability, F(3, 96) = 0.609,
p = .611, ηp2 = .019, or neighborhood density, F(3, 96) =
0.643, p = .589, ηp2 = .020, suggesting a phonotactic balance
across the four half-lists.
Participants were excluded from this analysis if they
were unable to complete the NU-6 or failed to produce a
word for more than half of their error responses. The final
data set for the phonotactic and neighborhood density
comparisons was derived from 68 participants (NBI-NH,
n = 24; NBI-HL, n = 27; PWA-NH, n = 13; PWA-HL,

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 Figure 8. Mean phoneme and biphoneme probabilities as a function of the Northwestern University Auditory
Test No. 6 (NU-6) word list. Error bars indicate the 95% confidence interval.

F(1, 64) = 2.866, p = .095, ηp2 = .041; and neighborhood ηp2 = .217 (see Figure 9). The NBI-NH group (M = 3.034,
density, F(1, 64) = 1.718, p = .194, ηp2 = .025. SE = 1.241) had significantly larger positive deviations from
Because the PWA-HL group retained only four par- target than the PWA-NH group (M = −5.657, SE = 1.687),
ticipants, analyses were performed with and without the F(1, 64) = 17.226, p = .0009, ηp2 = .212. The NBI-HL group
PWA-HL group to document whether the small sample (M = 1.097, SE = 1.17) also had significantly larger posi-
size in this group biased the relationship among the other tive deviation than the PWA-NH group, F(1, 64) = 10.824,
three groups. The total number of errors was compared p = .002, ηp2 = .145. No other group comparisons were sig-
across groups using a one-way between-subjects ANOVA. nificant for neighborhood density. Average deviation from
The average deviation from target for the errors also was
assessed with one-way ANOVAs applied separately for pho-
neme probability, biphoneme probability, and neighbor- Figure 9. Comparison of the error production by the four groups in
hood density as a function of group (including the PWA-HL terms of neighborhood density deviation from the target. PWA-NH =
group). The assumption of normality was met for each group persons with aphasia with normal hearing; PWA-HL = persons with
aphasia with hearing loss; NBI-NH = individuals with no brain injury
on all variables, and all other assumptions were met. with normal hearing; NBI-HL = individuals with no brain injury with
The number of error productions was significantly hearing loss.
different among groups, F(3, 64) = 9.742, p = .0009, ηp2 =
.313. Post hoc comparisons with Bonferroni correction
showed that the NBI-HL group (M = 8.833, SE = 1.407)
produced significantly more errors than the NBI-NH
group (M = 2.687, SE = 1.492), F(1, 64) = 8.979, p = .004,
ηp2 = .123, and the PWA-NH group (M = 1.962, SE = 2.028),
F(1, 64) = 7.752, p = .007, ηp2 = .108, but significantly fewer
errors than the PWA-HL group (M = 20.750, SE = 3.656),
F(1, 64) = 9.256, p = .003, ηp2 = .126. The PWA-HL group
had significantly more errors than the NBI-NH group,
F(1, 64) = 20.927, p = .0009, ηp2 = .246, and the PWA-NH
group, F(1, 64) = 20.201, p = .0009, ηp2 = .240. There was
no difference in the number of errors between the NBI-NH
and PWA-NH groups, F(1, 64) = 0.083, p = .774, ηp2 = .001.
These results are consistent with the previous analyses of
NU-6 performance using percent correct (in rau) as the
dependent measure.
The average deviation from target for neighborhood
density was significant for group, F(3, 64) = 5.921, p = .001,

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 target for phoneme probability deviation was not significant
for group, F(3, 64) = 1.656, p = .185, ηp2 = .072, and there
was no difference for average biphoneme probability among
the groups, F(3, 64) = 0.365, p = .778, ηp2 = .017.
The same analyses were completed with the PWA-HL
group excluded, and the results largely were unchanged for
the other three groups. A significant group effect was found
for the number of error productions, F(2, 61) = 16.171,
p = .0009, ηp2 = .346. The NBI-HL group produced signifi-
cantly more errors than both the NBI-NH group, F(1, 61) =
24.102, p = .0009, ηp2 = .283, and the PWA-NH group,
F(1, 61) = 20.810, p = .0009, ηp2 = 254. However, there
was no significant difference between the two groups with
normal hearing, F(1, 61) = 0.223, p = .638, ηp2 = .004. There
remained a significant group effect for average deviation
from the neighborhood density targets, F(2, 61) = 8.477,
p = .001, ηp2 = .217. As shown in Figure 10, the PWA-NH
group produced deviations from targets that were more neg-
ative than those produced by the NBI-NH group, F(1, 61) =
16.452, p = .0009, ηp2 = .212, and the NBI-HL group,
F(1, 61) = 10.338, p = .002, ηp2 = .145. However, there
was no significant difference between the two NBI groups,
F(1, 61) = 1.232, p = .271, ηp2 = .02. The average deviation
from the target phoneme and biphoneme probabilities were
not different among the groups, F(2, 61) = 2.414, p = .098,
ηp2 = .073 and F(2, 61) = 0.518, p = .598, ηp2 = .017, re-
spectively. The group means for phoneme probability,
biphoneme probability, and neighborhood density are sum-
marized in Table 5.
Discussion
NU-6 and PICA Scores
The results of this study suggested that people with
aphasia who are able to complete the NU-6 produced
results similar to adults without brain injury. About 73%
of the PWA in this study were able to complete the NU-6
in contrast to 100% of the NBI participants; yet all of the
PWA who were unable to complete the NU-6 successfully
completed the PIT. These findings indicated that the ability
to complete conventional open-set word recognition tests
was strongly influenced by verbal production and/or oral
motor capabilities as captured by the PICA verbal subtest
scores, primarily those from Subtests I and XII.
The verbal PICA scores predicted the ability to per-
form the NU-6, with the effect being binary in that the
correlation between verbal PICA score and NU-6 perfor-
mance was low and nonsignificant. Moreover, there was
likely a critical range of verbal PICA scores below which
PWA would not be able to complete an open-set word rec-
ognition test, and beyond the critical range, performance
was independent of the verbal PICA score.
Subtest XII (imitate/repeat names of common objects)
scores on the PICA provided a sensitive measure of the
ability to repeat words, which is a response requirement
of the NU-6. The results indicated that the NU-6 can be
administered with confidence to patients who produced an
average verbal PICA score of 11.61 (sensitivity = .792,
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specificity = .778), a value that should be an appropriate
cutoff score for screening purposes. A more conservative
cutoff of 13.46 (sensitivity = .542, specificity = .889) may
include patients who can successfully complete the NU-6,
but it will be more accurate in capturing those who should
be tested with some alternative tests, such as the PIT. With
a lower cutoff, such as 11.40 (sensitivity = .833, specificity =
.667), more patients can be tested with the NU-6, but there
is greater likelihood of increased frustration when a patient
has difficulty or is unable to perform the NU-6. There also is
a greater likelihood of misleading results if a patient does
poorly on the test.
The mean score for Subtest XII also produced poten-
tial cutoffs (14.45, 14.55) that clustered together within one
level and approached the values produced with the overall
verbal PICA, indicating a ceiling effect. Moreover, when
the administration and response variability of this subtest
is considered, Subtest XII might be less discriminating than
the overall verbal PICA score in detecting the ability to
complete the NU-6, but if clinicians wish to err on the side
of reducing the risk of failure or misleading results on the
NU-6, they might prefer to use Subtest XII cutoffs.
Poor performance on the NU-6 could be the result of
poor speech recognition, but it also could relate to speech
and language production difficulties. For example, one
PWA participant without hearing loss demonstrated 72%
percent correct on the NU-6 for both ears, a score more
than 15% lower than others in the same group. It is possible
that if the participant was tested with the PIT, performance
would have been higher. The participant’s verbal PICA
score was 9.75, and given a verbal PICA cutoff score of
11.61, the PIT was likely a more appropriate word recog-
nition test than the NU-6 for this person. Taken to the
extreme, it could be argued that any patient with brain injury
should be tested with an alternative test, such as the PIT,
where response demands are reduced. It also could be argued
that patients who require pausing and more time to respond,
even if they exceed the cutoff score on the PICA, might
benefit and be more efficiently tested with an alternative
test such as the PIT.
Aphasia and Hearing Loss
Word recognition scores on the NU-6 differed between
groups with normal hearing and those with hearing loss,
rather than between groups with and without aphasia, thus
indicating that the presence of aphasia alone did not account
singularly for performance on word recognition materials
after adjusting for age. With increased age, word recognition
performance decreased, a pattern found among all four
groups. Studebaker, Sherbecoe, McDaniel, and Gray (1997)
found that age had only a modest effect on the intelligibility
of monosyllabic words for people with normal or near-
normal hearing. However, removing the variance introduced
by age in this study was important for assessing the impact
of audibility and the influences of aphasia.
When hearing loss was introduced as a factor among
PWA, word recognition ability was affected but in the
13
 Figure 10. The error productions in relation to the targets in terms of neighborhood density. The diagonal straight line represents the correct
repetition of the target words. PWA-NH = persons with aphasia with normal hearing; PWA-HL = persons with aphasia with hearing loss;
NBI-NH = individuals with no brain injury with normal hearing; NBI-HL = individuals with no brain injury with hearing loss.

same way hearing loss affected the NBI participants. It
was evident that hearing threshold was the dominant effect
and largely independent of aphasia. This pattern of results is
consistent with early work by Jauhiainen and Nuutila (1977)
and more recently by Pratt et al. (2007), which showed that
the speech perception of stroke survivors was more adversely
affected by hearing loss and reduced audibility than the
presence of aphasia.
Although the current study did not focus on the impact
of hearing loss on aphasia, the descriptive data (Table 2)
showed that the overall PICA and overall mean CRTT score
of PWA with hearing loss were lower than PWA without
hearing loss—suggesting a potential negative influence of
the auditory impairment. Systematic investigation of the
effects of peripheral hearing loss on aphasia symptoms
and severity should be included in future research pursuits.

14 American Journal of Audiology • 1–18

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 Table 5. Summary of phoneme, biphoneme probability, and neighborhood density for the four groups.
Phoneme probability Biphoneme probability
Left ear Right ear Left ear
Group M SD M SD M SD
NBI-NH .045 .002 .047 .004 .0024 .00031
NBI-HL .046 .003 .046 .002 .0025 .00033
PWA-NH .045 .002 .047 .003 .0023 .00034
PWA-HL .046 .002 .046 .002 .0025 .00031
Note. NBI-NH = individuals with no brain injury with normal hearing; NBI-HL = individuals with no brain injury with hearing loss; PWA-NH =
persons with aphasia with normal hearing; PWA-HL = persons with aphasia with hearing loss.
Phonotactic Probability and Neighborhood Density
Essentially no significant differences in phonotactic
probability or neighborhood density were found in the cur-
rent study. What was most notable about the results of
phonotactic probability and neighborhood density was the
large variability within groups. However, there were some
interesting patterns worthy of discussion. Although not signif-
icant, the pattern of the results was consistent with the
assumption that the phonotactic probability and neighbor-
hood density properties of the errors were similar between
the two groups with normal hearing and between the two
groups with hearing loss but diverged between groups with
normal hearing and with hearing loss. According to the
neighborhood activation model proposed by Luce and
Pisoni (1998), spoken words are recognized in the context
of phonologically similar words activated in memory, which
then compete for recognition. The number of neighbors and
the frequency of those neighbors influence lexical retrieval
in speech production as well. During the retrieval process,
phonologically similar words may block or compete with
each other, resulting in slower and less accurate processing,
as they do in models of spoken word recognition (Vitevitch,
2002). Hearing loss has a direct impact on the accuracy of
word recognition because of missing or distorted informa-
tion that likely interacts with phonotactic probability during
speech perception tasks. Most errors occurred on high
phonotactic probability words within the NU-6 lists, which
is consistent with the neighborhood activation model pre-
dictions, but in some instances hearing loss might have
altered the composition of the word and its relationship
to potential competitors.
Theoretically, the average biphoneme probability
should reflect better a word’s average phoneme probability.
Because a biphoneme is inherently a larger phonological
unit than a single phoneme, it likely provides a more accu-
rate estimate of the probability of a meaningful word. In
the current study, a slightly different pattern of average
biphoneme probability from neighborhood density was
observed, probably due to differences in the calculations
and the different corpuses used in the calculations. The error
words’ average biphoneme probabilities obtained from the
two PWA groups were marginally higher than the target. In
addition, the difference between ears was slightly larger in
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Neighborhood density
Right ear Left ear Right ear
M SD M SD M SD
.0026 .00039 13.34 1.28 14.18 1.79
.0025 .00037 13.62 1.53 13.93 1.67
.0027 .00045 13.03 1.54 13.97 1.60
.0027 .00061 12.78 1.42 12.98 0.68
the groups with normal hearing than in groups with hearing
impairment for both phonotactic probability and neighbor-
hood density. However, the high levels of variability precluded
definitive conclusions about how hearing loss, phonotactic
probability, and neighborhood density interact, especially
in PWA. Nonetheless, the lack of significant differences for
the error patterns among groups provides some support for
the application of the NU-6 word lists with adults regard-
less of aphasia.
PIT
Because a majority of the participants with aphasia
were able to perform the NU-6, examination of the PIT
results relative to the NU-6 and the tests of aphasia was a
limitation. The PIT was administered to participants with
verbal PICA scores that were generally low, indicating
that speech/language production was a notable indicator
of whether a participant was able to perform the NU-6 or
needed the PIT to assess word recognition ability. Another
limitation was the small number of participants (n = 8) who
had aphasia and had been diagnosed and treated for their
hearing loss prior to their stroke. During our recruitment
efforts, it became evident that many clinicians were reluctant
to manage the hearing loss of PWA and that for some
participants and their families hearing loss was less of
a priority than their aphasia. Another consideration was
that a substantive number of the referrals with “normal
hearing” had undiagnosed hearing loss.
Aphasia is associated with attention and working
memory deficits that interfere with the ability to use lan-
guage, with some arguing that these deficits are the actual
source of aphasia (Hula & McNeil, 2008; McNeil et al.,
2004). As such, the added cognitive load and listening effort
observed with hearing loss and reduced audibility (McCoy
et al., 2005; Ng, Rudner, Lunner, Pedersen, & Rönnberg,
2013; Tun, McCoy, & Wingfield, 2009) likely has an adverse
impact on language and cognitive performance in many
PWA, which has consequences for accurate diagnosis,
prognosis, appropriate treatment, and quality of life. Thus,
it is important that PWA have access to prompt and appro-
priate audiological interventions. The impression of this
study that PWA have inadequate hearing healthcare war-
rants further investigation.
15
 Summary
A majority of the participants with aphasia were
able to complete the NU-6, and a picture-pointing response
format within the PIT was a viable means of assessing those
PWA who had substantively compromised speech and/or
language production abilities. The overall verbal PICA
score could serve as an indicator of the ability or inability
to complete an oral word recognition test. The effectiveness
of other tests of aphasia as a predictor needs to be exam-
ined separately. The results also indicated that most PWA
were able to perform clinical word recognition tests and that
performance was dominated by their hearing status rather
than their brain injury or aphasia. Although no significant
differences were found for the phonotactic probability and
neighborhood density of the error productions, investigating
the phonological characteristics of error words appears to
be worthwhile. That is, the origins of the speech errors in
the PWA were not differentially diagnosed in this sample,
and differential effects might be evident depending on
whether the errors were motor or linguistic in origin.
Hearing ability should be considered as a factor
that contributes to communication ability in poststroke
assessment. It is likely that individuals who have aphasia
are largely underserved when it comes to receiving hearing
healthcare. Pure-tone audiometry and acoustic admittance
measures are relatively easy to administer to PWA, but
word recognition testing might require some accommoda-
tions. Nonetheless, word recognition testing can provide
information about speech processing at a basic level and
can contribute to the differential diagnosis of PWA. More-
over, identifying factors that impact language processing
in PWA can potentially influence how professionals cate-
gorize, treat, and otherwise manage this population.
Acknowledgments
This material is based on work supported by the Department
of Veterans Affairs, Veterans Health Administration, Office of
Research and Development, Rehabilitation Research and Devel-
opment Service (Award C3118R to Patrick J. Doyle and Sheila
R. Pratt), and resources and facilities provided by the Geriatric
Research Education and Clinical Center in the VA Pittsburgh
Healthcare System. However, the contents do not represent the views
of the Department of Veterans Affairs or the U.S. Government.
The authors thank Brianna Nelms, MaryBeth Ventura, Tepanta
Fossett, Elizabeth Haley, and Cynthia Eberwein for their efforts
on this project.
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