Treatment of sentence comprehension and production in aphasia: is there cross-modal generalisation?

Figures & data

Table 1. Summary of treatment studies reporting uni- and cross-modal treatment effects following sentence comprehension and production treatment using MT, MT-act, and TUF.

Treated modality	Therapy approach	Study	n	Practice effect	Generalisation					Stability
					Uni-modal		Cross-modal
				To trained sentences	To trained structures	To untrained structures	To other modality	Task	Measure	in control task/pre-treatment baselines
Comprehension	MT	Jones (1986)	1	Not reported	Yes	Yes	Yes	PD	Verb inflection, sentence structures	Not reported
		Byng (1988)	2	Yes^s	Yes^s	Yes^s (n = 1), No (n = 1)	Yes^s	ST	VAS, sentence structures	Yes/Not reported
		Nickels, Byng, and Black (1991)	1	Not reported	No	No	Yes^s	ST	VAS	Yes^s/Yes
		Schwartz et al. (1994)	5	Yes^s (n = 4), No (n = 1)	Yes^s	Yes^s	Yes (n = 3), No (n = 2)	VD	VAS, MLU, N/V ratio, complexity	Not reported
		Mitchum et al. (1995)	1	Yes^s	Yes^s	Not reported	No	PD, VD	Expression of thematic roles	Not reported/Yes
	MT-act	Rochon and Reichman (2004)	1	Yes	Yes	No	Yes	Elicitation	Accuracy	Yes/Yes
	TUF	Jacobs and Thompson (2000)	2	Yes	Yes	No	Yes	Elicitation, ST	Accuracy, MLU	Not reported/Yes
Production	MT	Nickels et al. (1991)	1	Not reported	Not reported	Yes^s	No^s	SPM	Accuracy	Yes^s/Not reported
		Marshall, Pring, and Chiat (1993)	1	Yes^s	Yes^s	No	No^s	SPM	Accuracy	Yes/Not reported
		Byng, Nickels, and Black (1994)	3	Not reported	Not reported	Yes^s	Yes (n = 1), No (n = 2)	SPM	Accuracy	Not reported
		Weinrich, Boser, McCall, and Bishop (2001)	2	Yes (n = 1), No (n = 1)	No	No	Yes^s (n = 1), No (n = 1)	SPM	Accuracy	Not reported
		Rochon and Reichman (2003)	1	No	Yes^s	Yes	No	SPM	Accuracy	Yes/Not reported
		Rochon, Laird, Bose, and Scofield (2005)	3	Yes	Yes^s	Yes^s (n = 2), Yes (n = 1)	No^s	SPM	Accuracy	Not reported
		Harris, Olson, and Humphreys (2012)	1	Yes^s	Yes^s	Not reported	Yes^s	SPM	Accuracy	Not reported
	TUF	Thompson (1998)	1	Yes	Yes	Yes	Yes	SPM	Accuracy	Not reported/Yes
		Jacobs and Thompson (2000)	2	Yes	Yes	No	No	SPM	Accuracy	Not reported/Yes
		Murray, Ballard, and Karcher (2004)	4	Yes	Not reported	Yes (n = 2), No (n = 2)	No	SPM	Accuracy	Not reported/Yes (n = 3), Not reported/No (n = 1)
		Stadie et al. (2008) and Schröder et al. (2015)	7	Yes^s	Yes^s	Yes^s (n = 6), No^s (n = 1)	No^s	SPM	Accuracy	Yes^s/Yes^s

Notes: n = number of participants showing the respective result; Yes^S = statistically significant improvements, Yes = improvements reported without statistical computation; No^S = improvements statistically not significant, No = no improvements reported without statistical computation; not reported = no information available; PD = picture description; ST = storytelling; VD = video description; SPM = sentence-picture matching; VAS = verb-argument structures; MLU = mean length of utterance; N/V ratio = noun/verb ratio.

Table 2. Participants’ language profiles.

	CM1	CM2
Language Assessment Battery (Aachen Aphasia Test)
Syndrome classification	Broca	Broca
Severity grade (standard nine)	Moderate (4.2)	Moderate (5.2)
Token Test	86	51
Repetition: Sounds	29	89
Repetition: Single syllable words	28	90
Repetition: Foreign and loan words	31	93
Repetition: Morphologically complex words	23	84
Repetition: Sentences	25	44
Written language	27	65
Naming	44	70
Comprehension: Auditory	73	73
Comprehension: Visual	50	79
Pre-lexical and lexical processing of words/non-words (LeMo)
Auditory word-picture matching (n = 20)	19 (normal)	18 (impaired)
Auditory discrimination non-words (n = 72)	63 (impaired)	71 (normal)
Auditory discrimination words (n = 72)	67 (normal)	–
Comprehension of reversible sentences (Sätze verstehen)
Canonical active sentences (n = 40)	40 (normal)	31 (impaired)
Non-canonical active sentences (n = 40)	21 (chance)	22 (chance)

For subtests of the Aachen Aphasia Test (Huber et al., 1983), percentiles are provided. For selected tasks of LeMo (De Bleser et al., 2004) and selected subtests of Sätze verstehen (Burchert et al., 2011), the number of correct responses is provided with corresponding performance levels in parentheses (normal = scores within range of age-matched controls, impaired = scores below 2 SD from mean of age-matched controls, chance = scores within chance range).

Table 3. Examples for each sentence type.

ORC	Trained/Untrained Set 1 (n = 20)	case-marked (n = 10)	Ich sehe den Sohn, den der Vater badet. I see the son who the father is bathing.
		number-marked (n = 10)	Ich sehe das Kind, das die Tanten küssen. I see the child who the aunts are kissing.
	Trained/Untrained Set 2 (n = 20)	case-marked (n = 10)	Ich sehe den Vater, den der Sohn küsst. I see the father who the son is kissing.
		number-marked (n = 10)	Ich sehe die Frauen, die das Kind badet. I see the women who the child is bathing.
	Control Set 3 (n = 20)	case-marked (n = 10)	Ich sehe den Klempner, den der Mann ruft. I see the plumber who the man is calling.
		number-marked (n = 10)	Ich sehe die Echsen, die das Kamel schüttelt. I see the lizards who the camel is shaking.
SRC	Control (n = 10)	case-marked (n = 5)	Ich sehe den Koch, der den Gast schüttelt. I see the chef who is shaking the guest.
		number-marked (n = 5)	Ich sehe die Frauen, die das Schaf rufen. I see the women who are calling the sheep.
whoQ	Control (n = 20)	plural (n = 10)	Wen schubsen die Frauen? Who are the women pushing?
		singular (n = 10)	Wen fängt der Sohn? Who is the son catching?

ORC = object relative clauses; SRC = subject relative clauses; whoQ = who-questions.

Figure 1. Arrangement of the material during sentence comprehension treatment.

Figure 2. Timeline of the crossover treatment study, outline of tasks applied during assessments and sequencing of treatment phases. BL1/BL1’ = pre-treatment baseline assessments, post-Tx1/Tx2 = post-treatment assessments, Tx = treatment phase, ORC = object relative clauses, SRC = subject relative clauses, whoQ = who-questions.

Table 4. Controls’ performance (number and proportion of correct responses) and corresponding normal range (according to the criterion suggested by Crawford & Garthwaite, 2002) for the acting-out sentence comprehension task.

Sentence type	Mean correct (%)	Range (%)	SD	Normal range
ORC (n = 60)	59.5 (99)	58–60 (97–100)	0.42	59–60
SRC (n = 10)	9.8 (98)	7–10 (70–100)	0.51	9–10
whoQ (n = 20)	19.7 (99)	18–20 (90–100)	0.31	19–20

ORC = object relative clauses; SRC = subject relative clauses; whoQ = who-questions.

Table 5. Steps involved in the treatment of sentence comprehension and production.

Steps	Therapist	Participant
Sentence comprehension treatment
Probe 1	Presents ORC orally	Acts out the action with figurines
Practice phase	Repeats ORC + acts out with figurines Points to (a) action, (b) agent, (c) theme Introduces picture + written sentence Highlights agent on picture + written sentence
	Reads ORC Highlights theme on picture + written sentence	Selects the agent figurine Places agent on concept card (agent)
	Reads ORC Repeats ORC	Selects the theme figurine Places theme on concept card (theme)
	Names agent + theme
Probe 2	Presents ORC orally	Acts out the action with figurines
Sentence production treatment
Probe 1	Presents picture (A) + ORC orally Removes picture (A) Presents picture (B) + requests ORC	Produces ORC for picture (B)
Practice Phase	Introduces written sentence (1)	Reads sentence (1)
	Requests identification of agent + theme	Matches agent + theme to concept cards Points to agent + theme on the picture
	Introduces: (a) sentence (2), (b) relative pronoun	Reads written sentence (2) + relative pronoun
	Replaces theme in sentence (1) with Relative pronoun	Reads written sentences (2) + (1)
	Places sentences (2) + (1) side by side Shifts relative pronoun of sentence (1) between (2) + (1), resulting in ORC	Reads written ORC
	Mixes all word cards	Repeats derivation of ORC using sentences (1) and (2) as done by therapist Reads written ORC
Probe 2	Removes word cards Presents picture (A) + ORC orally Presents picture (B) + requests ORC	Produces ORC for picture (B)

ORC = object relative clause, e.g., I see the son who the father is kissing; picture (A) = depicted action, picture (B) = same depicted action as in (A) but with reversed theta roles; written sentence (1) = declarative canonical sentence, e.g., The father is kissing the son, written sentence (2) = matrix clause for ORC, e.g., I see the son.

Table 6. Number of correct responses, proportion correct and McNemar χ² comparisons for the two separate pre-treatment baseline assessments (BL1) and (BL1’) for each participant (p > .05 for all comparisons).

	CM1				CM2
	BL1	BL1’	χ^2	Performance level	BL1	BL1’	χ^2	Performance level
Production: sentence elicitation
ORC Set 1, n = 20	0 .0	0 .0	–	Impaired	2 .1	4 .2	0.5	Impaired
ORC Set 2, n = 20	0 .0	0 .0	–	Impaired	0 .0	4 .2	2.25	Impaired
ORC Set 3, n = 10	0 .0	0 .0	–	Impaired	1 .1	0 .0	0.1	Impaired
whoQ, n = 20	0 .0	0 .0	–	Impaired	9 .45	11 .55	0.25	Impaired
SRC, n = 10	–	0 .0	n/a	Impaired	–	4 .4	n/a	Impaired
Comprehension: acting-out
ORC Set 1, n = 20	11 .55	15 .75	1.5	Impaired	6 .3	7 .35	0.1	Impaired
ORC Set 2, n = 20	13 .65	15 .75	0.5	Impaired	6 .3	7 .35	0.1	Impaired
ORC Set 3, n = 20	13 .65	15 .75	0.5	Impaired	14 .7	10 .5	0.75	Impaired
whoQ, n = 20	20 1	19 .95	0.1	Normal range	19 .95	17 .85	0.25	Normal range
SRC, n = 10	–	10 1	n/a	Normal range	–	8 .8	n/a	Impaired

ORC = object relative clauses; SRC = subject relative clauses (assessed in BL1’only); whoQ = who-questions; n/a = not applicable. Performance levels are classified based on control data (see Table 4 for sentence comprehension norms and Schröder et al., 2009, for sentence production); normal range = within normal range; impaired = below normal range.

Table 7. Number of correct responses and proportion correct in production and comprehension after treatment in the same modality.

	CM1		CM2
	post-Tx1	post-Tx2	BL1	post-Tx1
Performance in production after treatment in production
ORC Trained, n = 20	0 .0	14* +++ .70	2 .10	8* +++ .40
ORC Untrained, n = 20	0 .0	14* +++ .70	0 .0	6* +++ .30
ORC Control, n = 10	0 .0	5(*) +++ .50	1 .10	4 .40
whoQ Control, n = 20	0 .0	2 .10	9 .45	10 .50
SRC Control, n = 10	0 .0	2 .20	4 .40	0 .0
	CM1		CM2
	BL1	post-Tx1	post-Tx1	post-Tx2
Performance in comprehension after treatment in comprehension
	BL1	post-Tx1	post-Tx1	post-Tx2
ORC Trained, n = 20	11 .55	19* +++ .95	4 .20	17* +++ .85
ORC Untrained, n = 20	13 .65	17 .85	3 .15	13* +++ .65
ORC Control, n = 20	13 .65	18 .90	7 .35	13 .65
whoQ Control, n = 20	20 1	19 .95	17 .85	9* −−− .45
SRC Control, n = 10	10 1	10 1	5 .50	1 .10

ORC = object relative clauses; SRC = subject relative clauses; whoQ = who-questions; BL = baseline.

*Significant change (McNemar, p < .05).

(*)Marginally significant at p < .07.

+/−Positive/negative effect, number of +/− denotes magnitude of the effect size (+/− = small ,++/−− = medium, +++/−−− = large).

Table 8. Number of correct responses and proportion correct in comprehension after treatment in the other modality.

Comprehension performance before and after production treatment
	CM2		CM1^a
	BL1	post-Tx1	post-Tx1	post-Tx2
ORC Trained, n = 20	6 .3	3 .15	17 .85	15 .75
ORC Untrained, n = 20	6 .3	4 .2	19 .95	17 .85
ORC Control, n = 20	14 .7	7* −−− .35	18 .9	15 .75
WhoQ Control, n = 20	19 .95	17 .85	19 .95	18 .9
SRC Control, n = 10	8 .8	5 .5	10 1	9 .9

ORC = object relative clauses; SRC = subject relative clauses; whoQ = who-questions; BL = baseline.

*Significant change (McNemar, p < .05); −−− = large negative effect.

^aFor CM1, changes in comprehension performance from post-Tx1 to post-Tx2 cannot be considered, as performance already increased between BL1 and post-Tx1 (i.e., after treatment phase 1).

Table 9. Number of correct responses and proportion correct in production after treatment in the other modality.

Production performance before and after comprehension treatment
	CM1		CM2^a
	BL1	post-Tx1	post-Tx1	post-Tx2
ORC Trained, n = 20	0 .0	0 .0	6 .3	8 .4
ORC Untrained, n = 20	0 .0	0 .0	8 .4	10 .5
ORC Control, n = 10	0 .0	0 .0	4 .4	1 .1
whoQ Control, n = 20	0 .0	0 .0	10 .5	13 .65
SRC Control, n = 10	0 .0	0 .0	0 .0	2 .2

ORC = object relative clauses; SRC = subject relative clauses; whoQ = who-questions; BL = baseline. None of the comparisons reached significance.

^aFor CM2, changes in production performance from post-Tx1 to post-Tx2 cannot be considered, as performance already increased between BL1 and post-Tx1 (i.e., after treatment phase 1).

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