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					ASHA session nr. 1102

The efficacy of Lexical - Semantic vs. Phonological Therapy in Aphasia
Evy Visch-Brink & Marjolein de Jong-Hagelstein
Erasmus Medical Center Rotterdam, The Netherlands

An RCT (Doesborgh et al. 2004) that reported according to the Consolidated Standards of Reporting
Trials (CONSORT) statement (Begg et al. 1996) compared the effects of BOX (Visch & Bajema 2001)
with the effects of phonological therapy: FIKS (van Rijn et al. 2000). FIKS is focused on sound
structure. As in BOX, written exercises on word, sentence and text level are presented, directed at the
phonological input and output routes. There are 10 subparts with several levels of difficulty with > 1000
exercises: Rhyming, Consonant Clusters, Stress Patterns, Compiling Words, Word Length, Phonemic
Similarity, Texts, Phonetics and syllabification, Homophones, Analysis and synthesis.

A total of 58 patients with a semantic and a phonological deficit from 35 Dutch clinical centres were
randomised. The intention-to-treat group (with pre- and post-treatment scores, but too few hours of
therapy) consisted of 55 patients, the on-treatment group (with at least 40 hours of therapy) consisted
of 46 patients
Treatment: Treatment started at 3-5 months after onset and lasted until 10-12 months post-onset.
Treatment was comprised of 40-60 hours of individual treatment (1.5-3 hours a week in 2 or 3
sessions). Besides the assigned language treatment, no other language treatment was allowed.

The primary outcome measure was the ANELT, scale A (Understandability), Blomert 1995. Patient
responses were tape-recorded and scored by two independent observers blinded to test moment (pre-
treatment or post-treatment) and treatment allocation. The mean of the two observers’ scores was
used in the analyses. The specific semantic measures used were: the SAT (Semantic Association
Test, Visch-Brink et al. 2005) and Synonym Judgement (PALPA). The specific phonological measures
used were Repetition Nonwords (PALPA), and Auditory Lexical Decision (PALPA).

After treatment, analyses of both the intention-to-treat and the on-treatment groups showed that the
mean ANELT score improved significantly in both groups. No significant difference between the
semantic and phonological groups was found when final ANELT scores and mean improvement were
compared (see Table 1).
Table 1.         Comparison of ANELT score between patients who were randomized to
semantic treatment (n=29) and to phonological treatment (n=29)

intention-to-treat (n = 55)

                               Semantic treatment         Phonological treatment        Difference
                               (n=29)                     (n=26)                        Mean (95% C.I.)
Mean final score (sd)          29.9 (12)                  29.5 (11)                     0.4 (-6.0; 6.9)

Mean improvement (sd)
                               5.1 (9)                    6.2 (7)                       -1.1 (-5.3; 3.1)

on-treatment (n = 46)

                               Semantic treatment         Phonological treatment        Difference
                               (n=23)                     (n=23)                        Mean (95% C.I.)
Mean final score (sd)          31.3 (12)                  30.2 (11)                     1.1 (-5.9; 8.0)
Mean improvement (sd)          6.4 (6)                    6.5 (7)                       -0.1 (-4.0; 3.9)

Treatment-specific effects were found at the impairment level. After semantic treatment, patients
improved significantly on a semantic measure (Semantic Association Test; SAT, Visch-Brink et al. ).
After phonological treatment, patients improved significantly on the phonological measures (repetition
Nonwords, Auditory Lexical Decision) (see Table 2).
Table 2.         Progress of on-treatment groups on semantic and phonological measures

                                  improvement after   improvement after         difference between
                                  semantic            phonological              treatment groups
                                  treatment (n=23)    treatment (n=23)          Mean (95% C.I.)
                                  Mean (95% C.I.)     Mean (95% C.I.)

Semantic measures

Semantic Association Test         2.9 (1.2; 4.6)*     1.6 (-0.2 ; 3.3)          1.3 (-1.0; 3.7)
(max. 30)
Synonym Judgement                 1.7 (-1.1; 4.5)     0.1 (-2.3; 2.4)           1.6 (-1.9; 5.2)
(max. 60)

Phonological measures
Repetition Nonwords               1.3 (-1.2; 3.7)     3.0 (1.4; 4.7)*           -1.7 (-4.6; 1.1)
(max. 24)
Lexical Decision                  -0.5 (-2.9; 1.7)    3.0 (1.2; 4.7)*           -3.5 (-6.3; -0.7)*
(max. 80)

* indicates significant difference (p<0.05)

Improvement at the impairment level was related to improvement on the ANELT. In the semantic
group, there was a correlation with one of the semantic measures (SAT), whereas in the phonological
group, there was a correlation with one of the phonological measures (Repetition Nonwords).

This study is one of the few RCTs in which a specific aphasia treatment method is evaluated and in
which an outcome measure of verbal communication is used. After both semantic and phonological
treatment, patients with a combined semantic and phonological deficit improved on the ANELT, a
measure with strong ecological validity. At the impairment level, patients improved on a semantic
measure after semantic treatment and on phonological measures after phonological treatment.
Moreover, in both treatment groups, therapy-specific correlations between improvement on the ANELT
and improvement on semantic versus phonological measures were found. These specific effects
challenge the interpretation that the equal improvement in verbal communication in both groups is a
result of spontaneous recovery. Moreover, Laska et al. (2001) found no progress on the ANELT at 3
months post-onset in an unselected group of 119 patients. All patients entered our study at least 3
months post-onset. The different effects found at the impairment level also suggest that each
treatment achieved improvement at the activities level (verbal communication) in a different way, and
not merely as a result of non-specific effects such as being engaged in language exercises, receiving
attention, or being stimulated. The treatment-specific effects we found at the impairment level suggest
that there may be two routes that lead to improved verbal communication: a semantic route and a
phonological route.
With reference to this RCT, BOX is evaluated in an ‘evidence-based review of stroke rehabilitation’ (a
publication of the Canadian Stroke Network, Salter et al. 2006) on the 1b level: ‘’There is moderate
evidence that task-specific semantic therapy improves semantic activities’. BOX is also included in the
treatment methods in the evidence-based aphasia clinic (EBAC) in Washington (U.S.A.) (Fucetola et
al. 2005).

In a second RCT the efficacy of BOX & FIKS (Cognitive Linguistic Therapy) is compared with the
efficacy of Communicative Therapy. Both therapymethods are applied in the first 6 months post onset.
The results will be presented.


Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I. et al. Improving the quality of randomized
controlled trails. JAMA 1996; 276: 637-639.

Blomert L, Koster Ch, Kean ML. Amsterdam-Nijmegen Test voor alledaagse taalvaardigheid, 1995.
Lisse: Swets & Zeitlinger.

Doesborgh SJC, van de Sandt-Koenderman MWE, Dippel DWJ, van Harskamp F, Koudstaal PJ,
Visch-Brink EG. Effects of semantic treatment on verbal communication and linguistic processing in
aphasia after stroke: a Randomized Controlled Trial. Stroke 2004;35 (1): 141-146.

Fucetola R, Tucker F, Blank K, Corbetta M. A process for translating evidence-based aphasia
treatment into clinical practice. Aphasiology 2005; 19: 411-422.

Laska AC, Hellblom A, Murray V, Kahan T, Arbin M von. Aphasia in acute stroke and relation to
outcome. Journal of Internal Medicine 2001; 249: 413-422.

Salter K, Teasell R, Bhogal S, Zettler L, Foley N, Orange JB, Speechley M. Evidence-based review of
stroke rehabilitation: Aphasia. Canadian Stroke Network 2006, 9 Edition.

Van Rijn M, Booy L, Visch-Brink EG. FIKS, een fonologisch therapieprogramma, 2000. Lisse: Swets &
Visch-Brink EG, Bajema IM. BOX, een semantisch therapieprogramma. 2001. Lisse: Swets &

Visch-Brink EG, Stronks DL, Denes G. Semantische Associatie Test, 2005. Amsterdam: Harcourt.

BOX, a lexical semantic therapy programme for aphasic patients
(Visch-Brink & Bajema 2001)

7 subparts

    I.        Semantic Categories

A number of semantically related words is given, together with one word that belongs to a
different semantic category. The patient has to pick the odd one out. Furthermore, each level
of difficulty has its own additional task which may either be used separately, or enable the
patient to find the solution to the initial task. At the first level, three categories are given, one
of which presents the category to which the semantically related words belong. At the second
level, a sentence is given which relates to all the words in the previous task, except for the
distracter. At the third level, two sets of five semantically related words are mixed up, and the
patient has to separate them according to category.

Level 1                        Level 2                                 Level 3

letter                         comma                                   graetness
postcard                       number                                  superiority
sigar                          question mark                           power
bill                           semi-colon                              motivation
                               parentheses                             authority

mail                           The editor of the local                 greatness
cutlery                        newspaper complains about               superiority
clothes                        the inaccurate writing style            frequency
                               of his correspondents                   importance

    II.       Syntagmatic and Paradigmatic Relationship
A word has to be matched with another word (two or three possibilities are provided). The
match either constitutes a syntagmatic or paradigmatic relationship. If the patient needs help,
a sentence is provided which explains the relationship of the two words. At the first level of
difficulty, a choice has to be made out of two semantically unrelated words. At the second
level, the two possibilities share a semantic similarity, although only one of them matches
with the target word. At the third level, the patient has to choose one out of three semantically
related words.

Level 1                         Level 2                     Level 3

CRISPS                          THEATRE                     INTERPRETER

popcorn / towel                 musical / home movie                actor / translator / courier

Let’s have something            It appears that the show    The Russian ambassador
to go with our drinks.                 is sold out.               Is coming to Holland.

    III.    Semantic Gradation

Words have to be matched with one of two antonyms. There is only one level of difficulty.



blossom                  cleaning
mushroom                 chestnut
first cuckoo             September
lamb                     bird’s nest
fall of the leaf         harvest-time
Easter                   acorn

    IV.     Adjectives and Exclamations

A sentence implies the meaning of an adjective, which is presented in a number of sentences.
The patient has to pick out the alternative that goes with the stimulus sentence. This form of
exercise is modified at level 3 in which the alternatives consist of exclamations. At the first
level of difficulty, the alternatives consist of two sentences with opposite adjectives. At the
second level, the patient has to choose from three sentences, each of which could be compared
with the stimulus sentence, though only one is implied from it. The exclamations in level 3
are the most abstract items in this part of the programme.

Level 1                                 Level 2                     Level 3
The boy from next door                That piano makes                I’ve got my
is playing in the mud                  a terrible noise               driver’s license

1.The boy from next door              1. The piano is white           1. Oh dear
  is dirty                            2. The piano is new             2. Congratulations
2. The boy from next door             3. The piano is out             3. Is that so?
   is clean                              of tune

   V.      Part Whole Relationship

A target sentence gives an example of a part whole relationship between two content words.
The alternatives consist of a number of content words, one of which has the same sort of
relationship with the stimulus content word. At the first level there are five possibilities to
choose from, and the distracters are semantically unrelated to the correct items. There is
variability in the number of words that is correct. At the second level there are four
semantically related words only one of which is the correct choice. The third level has three
semantically related possibilities. The difficulty of this level is established through the
semantic ambiguity of the target word (the patient has to switch from one meaning to

Level 1                       Level 2                         Level 3

The towels are                That painting                   A cat’s tail
in the linen-cupboard         has a nice list

dishcloth                     portrait                        frock
grassmower                    aquarelle                       dress
handkerchief                  film                            coat

   VI.     Anomalous Sentences

Sentences are presented to the patients that are either semantically correct or incorrect. The
patient has to make a yes/no decision. Only levels 1 amnd 2 are represented in this task.
Sentences of level 2 are longer and more complicated than those of level 1.

Level 1                       Level 2

The sun rushes                Dior’s newest perfume
through the country           smells like a fresh spring

The towel falls into          The church tower gradually
the bath water                grew upset in 1667
    VII.     Semantic definition

At the first level a word is given which can also be used in compound words. Eight
possibilities follow of which the patient has to decide whether the combination makes a legal
compound, yes or no. At the second level, compound words are given followed by two
definitions, one correct and one false. At the third level, a list of words is presented, followed
by three short definitions, some of which apply to more than one word.

Level 1                       Level 2                        Level 3

ROPE                          evening dress                  queen
ropedancer                    1. dress that can be worn      chicken
ropeladder                       at a dinner party           horse
ropemidday                    2. kind of pyjama              jack
ropewalk                                                     mouse
ropequoit                     evening star
ropemap                                                      which one is:
ropeyard                      1. planet seen after sunset
ropegrease                    2. rock singer who starts      part of a computer
                                 his performance             an animal
                                  after 10. p.m.             part of game of chess

   VII.    Semantic Context

This part of the programme contains only exercises on text level. At the first level, fairly short
texts are presented with one or two sentence anomalies in them. In an additional task, the
patient is presented with a similar text without anomalies, and has to make a decision as to
what kind of text he is confronted with. At the second level, a text is given together with two
summaries. At the third level, a newspaper text is presented, with erroneous content words,
which the patient has to spot.

Level 1

Aquarius April 25 – May 1

You are doubting and wavering, but the stars predict there will soon be an end to all your
problems. Visit your friends, go shopping. You will meet someone interesting at a birthday
party. There’s a chance you may even win the presidential election! Beware of a jealous
woman. Also take care of your health

Is it
a prize content
a horoscope
a dietary advice

Level 2

A well known pianist was addressed by a lady and her nine year old son, just after a concert.
The lady wanted the pianist to listen to the boy’s playing. The pianist said he really was too
busy to give an audition, however, the mother managed to get an appointment for the
following day. The son played a Waltz by Chopin. When he had finished, the pianist said it
was the most horrific piano-playing he had ever heard. Quite satisfied the mother said to her
son: ‘See! Now will you finally stop your lessons and start playing football?’

Which is the right summary?

   1. A famous pianist was addressed by a lady and her nine year old son. The lady wanted
      the pianist to listen to her son’s playing. The pianist said he played very badly. The
      mother was furious and went to another musician.

   2. A famous pianist was addressed by a lady and her nine year old son. The mother
      wanted the pianist to listen to her son’s playing. When the pianist said he played very
      badly, she was quite satisfied.

Level 3

Napoleon forbidden to walk around

Coventry- The City Council of Coventry has decided that tom-cat Napoleon is no longer free
to walk around. The cat was the fright of the neighbourhood. It suffers from a kidney disease
because of alcoholism. Not content with its daily meals, it walks into neighbourly houses to
steal away food from other cats. When they protest, Napoleon beats them up. The owner of
three other cats complained to the police, and thus Napoleon got grounded.
FIKS, a phonological therapy programme for aphasic patients
(van Rijn, Booy, Visch-Brink 2000)

10 subparts

I.           Consonantclusters
II.          Stress patterns
III.         Lexicon
IV.          Wordlength
V.           Phonological similarity
VI.          Texts
VII.         Phonetically written words
VIII.        Homophones
IX.          Analysis & Synthesis
X.           Rhymes

I.      Consonantclusters

•  Reading aloud and repetition words with one or more consonantclusters of 2, 3
crash, script

• Cluster selection
..aise pl gr pr

• Finishing clusters

II.      Stress patterns

• Judgment stresspattern
Atlantic, Atlantic, Atlantic (listening, reading)

•     Reading aloud 2-, 3- syllabic words with same stresspattern

•     Correction wrong stresspatterns multisyllabic words

• Selection words with same stresspattern

III.      Lexicon

• Word selection (reading aloud)
termat matter
cidentin dentinci incident

• Compiling words

• Finishing words

• Reading aloud irregular words

IV.       Wordlength

•      Counting syllables in heard words (1,2,3 syllables)

•      Judgment same / different words in terms of amount of syllables (reading aloud and
       heard words)

• Selection words with same amount of syllables
relevant saying satellite slogan

•      Repetition and reading aloud multisyllabic words (2 to 6 syllables)

V.        Phonological similarity

•      Judgment same/different vowels in words and word groups (reading or listening)

•      Reading aloud multisyllabic words or word groups with similar vowels

VI.       Texts
 • Reading aloud and repetition of sentences with similar vowels
There is a lot of action on Roberts’ reception

• Reading aloud text, directed to one or two phonemes
Boer Bloem boert goed (dutch)

• Reading aloud nonwords in text, directed to one or more phonemes
De kwes peepte de weespeters zozer mee, dat de neelnemende sterplegers vervreesd waren
voor aangelukken

VII. Phonetically written words

    •    Reading aloud and afterwards repetition of two- and more-syllabic words

VIII. Homophones

    •    Reading aloud words, judgment yes or no homophones

    •    Selecting homophones from a row of words

IX.        Analysis & Synthesis

    • Reading aloud 1st and last phoneme of a word

    •    Counting phonemes of an auditorily presented word

    • fill in phonemes in word or word group
    …ouse (m,p,b), dr.nken .ailor

    • Making a w word with first or last phoneme
    book kind

    • Making new word with first or last phonemes of 3 words
    mall arm no

    • Read aloud or say a word in reverse order
    rot tor (English: f.i. wall law)

    •    Repetition nonwords

X.         Rhyming

•       Selection one or two rhymewords (T. presents target)
man : kin van day

• Selection one or two rhymepairs (P. reads aloud)
kind moon down mind soon

• Selection rhyming sentences
There was a long row
 The temperature was high
 The temperature was low

•   Selection rhyming sentences from two rows

•   Production rhyming words

•   Production rhyming sentences, T. gives 2 words: man, van

•   Reading aloud short poems
n rhyming words

•   Production rhyming sentences, T. gives 2 words: man, van

•   Reading aloud short poems