1. Evidence Based Aphasia Therapy after 15 years Now What?
MACDG
November 4, 2015
St. Louis, Missouri
Sharon M. Holloran M.A.CCC
Lead Speech Pathologist for the Evidence Based Aphasia Clinic
The Rehabilitation Institute of St. Louis

3. EBAC Patients (2001-2014) (not including 25 extremely severe patients, and non-covered)
Characteristic
Number/316
Percentage
Male
Female
184
132
58.2%
41.8%
Age
(16-90)
Anomic
Global
Mixed nonfluent
Wernicke’s
Transcortical sensory
Broca’s
Transcortical motor
Conduction
Unclassifiable
101 66 27 23 17 16 8 3
32%
21%
8.5%
7.3%
5.4%
5.1%
2.5%
<1%
Fluent
Non-fluent
191
125
60%
40%
Weeks post-event
(range)
(1-1248)

4. EBAC Patients (2001-2014) Etiology Number/316 Percentage
LMCA ischemic stroke
Left hemorrhagic stroke
194 66
61%
21%
Left subcortical only ischemic stroke 16 5%
Left hemisphere tumor
Left hemisphere traumatic brain injury (TBI)
Left ACA or PCA ischemic stroke, or subarachnoid hemorrhage 13 11 6 4% 2%
Infectious, seizures or multiple sclerosis

5. EBAC Patients (2001-2014) Baseline Measures (pre-treatment)
Mean (sd)
Possible range
BDAE Language Competency Index (LCI)
LCI-Expressive
LCI-Comprehension
37.9 (28)
38.3 (31)
37.4 (30)
0-100
Boston Naming Test (BNT)
19.5 (20)
0-60
Communication Activities of Daily Living (CADL-2)
63.9 (26)
ASHA Quality of Communication Life Scale
3.78 (0.7)
0-5
Communication Effectiveness Index (CETI)
53.4 (23)

6. Levels of Evaluation of Change
Baseline
1-month
2-month
3-month
4-month
5-month
6-month X
X/X
Aphasia diagnostic exam
Nonverbal cognitive testing
Mood/QOL/functional comm.
Family rating of change
Discourse measurement
Treatment data-trained
Treatment probe-untrained
Treatment probe-control behavior

7. Measurement Neuropsychology Measures
Boston Diagnostic Aphasia Evaluation
Communication Activities of Daily Living-2
(CADL-2)
Boston Naming Test
ASHA Quality of Communication Life
Visual Analog of Mood Scale

8. Speech-Language Measures
Western Aphasia Battery (WAB)-Initial Evaluation
Aphasia Quotient
Communication Effectiveness Index (CETI)-monthly
16 items to rate client with aphasia
Discourse Comprehension Test-monthly
2 stories , 8 y/n questions on each
BDAE Discourse Production Measure (Aesop fable story retelling)-monthly
Story retelling task yields 3 scores

9. Scoring CETI - mark a line 10 cm long on 16 items and find average
DCT- read 2 stories, ask 8 y/n ?’s per story
Discourse Production- retell Aesop’s fable & record
Ideally linded SLP takes measures and transcribes & scores

11. Discourse Production PROBE
Video of Aesop’s Fables

13. Development of an EBAC (2001)
Development of treatment care paths
Care paths for primary areas of language competence
Verbal expression
Auditory comprehension
Reading
Written language
Include treatments aimed at activity/participation level

22. Effect Size
Effect size refers to a family of indices specific to single subject design that establishes the magnitude of gain from treatment.
Effect size is defined as a “ quantity that describes the degree to which a treatment outcome differs from zero.( Beeson & Robey, 2006 )

23. Effect Sizes Small effect size = 0.2 Medium effect size = 0.5
Large effect size = 0.8

24. Effect Sizes (d)
Word-finding treatment for anomia in aphasia 1.66 Viagra (oral sildenafil) vs. placebo and self-reported 1.60 change from baseline in sexual functioning Effect of low dose prednisone vs. placebo on number 1.05 of swollen joints in rheumatoid arthritis Computerized cognitive rehabilitation post-stroke 0.54 Effect of donepezil on cognition in Alzheimer’s 0.51 Improvement in depression with paroxetine 0.21 vs. placebo
Wisenburn in meta analysis of 44 studies and 107 effect sizes that just came out this year – analysis of various approaches for word finding deficits in people with aphasia – phonological, semantic and mixed. Semantic therapy appeared to have more generalization to untrained words.
Wisenburn & Mahoney, 2009; Althoff et al., 2003; Katzman et al., 2007; Winblad et al., 2009; Saag et al., 1996; Cha & Kim, 2013

25. Effect Sizes Wisenburn and Mahoney, 2009
Completed a meta-analysis of 44 studies and 107 effect sizes that just came out this year
Analysis of various approaches for word finding deficits in people with aphasia- semantic, phonological, and mixed
Revealed semantic therapy appeared to have better generalization to untrained words

26. Aphasia Treatments How to implement programs in your setting.
MACDG
November 4, 2015
St. Louis, Missouri
Jacque Livingston M.A.CCC
Speech Therapist at The Rehabilitation Institute of St. Louis
The Rehabilitation Institute of St. Louis

27. EXPRESSIVE PROGRAMS (In order of typical progression)
PROMPT
Gestural Verbal Treatment (GVT)
Script Training
Semantic Feature Analysis (SFA)
Phonological Component Analysis (PCA)
VNeST
Response Elaboration Treatment (RET)

28. Tactile treatment for motor speech disorders
PROMPTS for Restructuring Oral Muscular Phonetic Targets
Used with patients 6 months of age onward.
Speech Pathologists are the only professionals with the prerequisite knowledge to apply PROMPT
To become fully trained in PROMPT, a clinician must complete four essential steps to be able to fully understand the PROMPT technique and apply it appropriately to patients
Introduction to PROMPT, Bridging PROMPT to intervention, The PROMPT technique self study, PROMPT Certification: A Self-Study Project
Website: promptinstitute.com

29. Using Tactile Prompts in Therapy
Voicing/Breath
Labial
Jaw Height
Lingual
Valving

30. Voicing Start here in the non verbal patient
May need oral stimulation (e.g. tactile, thermal, gustatory) before treatment to prime articulators
Tactile prompt to diaphragm, chest, and larynx
Teach inhale then voicing on exhale
Prompt mouth open to initiate voicing

31. Labial placement Video labial closure/labial retraction
Video labial rounding
Labial opening (voicing)
Labial closure (bilabials)
Labial retraction (/i/)
Labial rounding (/o/ /oo/)

32. Lingual Placement Video for velar placement
Use verbal cue for lingual placement and position
Front, middle, back
Use modeling for visual and phonemic cues
Decrease cueing hierarchy, tactile→verbal →visual →independent
Notice pt is self prompting

33. Nasals Video for nasal sound Prompts for valving on /m/ /n/
Prompt for air through nose
Prompt for lingual postion of /n/
Prompt for labial positions of /m/
Use with minimal pairs, ex mom vs mop teaching pt to redirect air from nasal cavity to oral cavity
Prompt to nose Pt is redirecting air flow from nasal cavity to oral cavity

34. Putting it together
Video of Prompt workshop

35. Gestural Verbal Treatment GVT

36. Gestural Verbal Treatment
Targets verbal production
Pt population typically non fluent with mild to severe aphasia/apraxia of speech
Pair intact gesture to facilitate production of verbal expression
Target gestures should be functional
May increase from word to phrase length verbalizations
Use gesture which best illustrates target word

37. Gestural Verbal Treatment
Target pic placed in front of subject and a model of the verbal and gestural target provided
Gesture elicited in isolation following a model
Verbal production elicited in isolation following a model
Verbal and gestural responses are modeled together while client produces simultaneously
Verbal and gestural response elicited together without a model
Each training item is presented two to three times per treatment session.

38. Gestural Verbal Treatment Video
Video of GVT

39. Script Training

40. Script training
Script Training was initially developed to promote verbal communication on client-selected topics (Holland, Milman, Munoz, & Bays, 2002)Goal is for individuals for whom speech is no longer automatic to produce islands of fluent speech in conversation
Previously used as a treatment approach to improve automatic language production in adults with aphasia
To become automatic, scripts must be practiced as phrase or sentence-length units vs. syllable or ‘one word at a time’ approach (Youmans, Holland, Munoz, & Bourgeois, 2005)
For individuals with expressive speech difficulties repeated practice of phrases and sentences can lead to automatic and effortless speech productions

41. Script Training
Work with patient to create 3 scripts. Each script should consist of 3-4 relatively short sentences.
Example: Conversation Starters:
How are your grandchildren?
Good morning.
I’ll see you later.
What’s new?
Utilize cuing hierarchy to introduce scripts.
Phrase repetition
Choral reading with clinician
Independent production
When the client can produce a newly trained phrase independently at least 20 consecutive times a new script is added or more information is added to mastered script.
Patient’s are expected to practice scripts at home for 15 minutes per day.
Once a script is mastered, generalization training is initiated.
Clinician purposefully varies response and comments to help the participant make scripts more resilient and more flexible.
Which you will see Karen do in

42. Script Training Data Collection
DATE
6/14/12
6/4/12
6/19/12
6/21/12
6/28/12
7/2/12
7/5/12
7/10/12
7/12/12
7/17/12
7/19/12
Script 1 40 60 70 90 96 93 94
Time
3:00
2:45
1:56
1:35
1:13
1:10
1:27
1:02
1:00
Script 2 39 38 81 86 95 99
5:00
2:25
2:05
2:10
1:11
1:20
1:01
Script3 78
2:47

43. Semantic Feature Analysis

44. Theory of SFA
There are strong neural connections between related concepts
There is better access to word-finding within categories
SFA allows pt’s to self cue by activating these neural connections
The 2009 study by Antonucci
pts treated with SFA during discourse production tasks showed improvements in general communication efficiency
2010 Peach and Rueter
showed that targeting word finding behaviors in connected speech generalized to naming of untrained object and action pictures
SfA only tx that shows improvements in untrained targets as it assists with circumlocution which assists in word retrieval during anomic events.

45. Model for SFA
SFA model involves description of a target item (picture in the center of the template) which enables the pt. to generate features including:
Group
Use
Action
Properties
Location
Association

46. Semantic Feature Analysis (Nouns)

47. Semantic Feature Analysis

48. Semantic Feature Analysis Video
Video of SFA

49. Phonological Component Analysis
The Phonological Component Analysis was modeled after SFA through spreading activation (Boyle and Coehlo, 1995)
The PCA protocol (Coehlo, 2008) followed the protocol of a target picture presented in the center of the chart with the pt asked to identify 5 phonological components related to the target:
-rhyming
-identify the first sound of the word
-first sound association
-final sound
-number of syllables

50. PCA TEMPLATE

51. Visual Network Stregthening Treatment
VNeST

52. VNEST
Verb Network Strengthening Treatment (VNeST) (Edmonds et al., 2009)
Semantic treatment - to improve lexical retrieval of content words in sentence context
Promotes systematic retrieval of verbs and their thematic roles
Treatment uses co-activation of verbs and their thematic roles so that a verb primes its agents (arresting/policeman), patients (arresting/criminal) and instruments (cutting/scissors) and vice versa.

53. VNeST Procedure VNeST: Procedure (Edmonds et al., 2009)
1.Generation of three agents or patients for verb (using who/what & verb cards; if cannot produce 3 words, then can select cards from choice of target plus 3 foils)
2.Generation of corresponding agent or patient to complete agent–patient pairs; reads word pair aloud
3.Answer wh-questions about agent–patient pair (when, where, why)
4.Semantic judgement of sentences read aloud by clinician

54. Vnest Template Step one: ( who)determine agent or patient for “verb”
Step two: corresponding agent or patient
Step three: where, when, why
Typically treament primes pt for RET as it is a more structured tx but still utilizes wh questions to assist with expansion of utterance and subject verb object clauses increasing LCI

55. Response Elaboration Treatment RET

56. Response Elaboration Treatment
Targets increase the length and information content of verbal responses
The goal of this therapy is to reinforce and elaborating on the language of the aphasic patient. 
A typical session involves a six step training sequence.
The patient is presented with a picture stimulus and responds with a spontaneous description.
The clinician then expands and reinforces the patient’s response. After cueing and repetition requests, the patient will ideally be able to lengthen the understanding of the stimuli and number of words used to describe it.

57. Response Elaboration Treatment (RET)
Procedure
Stimulus presented (e.g. personal picture, magazine photo, etc. Must be action on photo)
Clinician: “What is happening here?”
Patient: “Crying.”
2. Expansion/reinforcement
Clinician: “Good! The boy is crying.”
“Why” cue
Clinician: “Why is the boy crying?”
Patient: “Hit head.”
Combining patients response, modeling
Clinician: “Great! The boy is crying because he hit his head.”

58. Response Elaboration Patient Data
                                           
11/15
11/19
11/26
12/3
12/6
12/10
12/13
12/17
12/27
1/7
1/14
1/17
1/21
1/28
1/31 10 12 17
10.5
12.1 9 13 15 14 16 18 23
0.11
0.08
0.09
0.1
0.13
0.125
0.165
0.14
0.17
Date
Content Units
Efficiency
Content Units= information (nouns, verbs, adjectives relevant to topic)
Efficiency= content units/time
2/9/11
2/22/11
3/2/11
3/9/11
3/24/11
3/30/11
4/20/11
5/18/11
6/18/11
LCI
0.6 1
0.75
1.2 
# clauses 2
3.0
5.0
 6.0
2.0
7.0
8.0
Date

59. Response Elaboration Video
Video of RET

60. Receptive Programs Treatment for Wernicke’s Aphasia (TWA)
Complex Semantic Naming

61. Treatment for Wernicke’s Aphasia
Developed by Helm-Estabrooks and Fitzpatrick
Based on the evidence that the ability to repeat orally presented stimuli may be linked to the ability to process or understand these stimuli
Appropriate for moderate to severe Wernicke’s Aphasia
Pt. must demonstrate good ability to understand written stimuli at the single word level and some ability to correctly read single words aloud
Pt should have reading intact at the word level

62. TWA
Treatment Steps
Step 1: Reading Comprehension: match a printed, lowercase word to its pictorial representation with 6 pictures (one correct and five foils)
Step 2: Oral Reading: read the target word aloud (with no pictures out)
Step 3: Repetition: repeat the word as presented by the clinician with only the picture present (no printed stimuli)
Step 4: Auditory Comprehension: correctly select the pictorial representation of the word from a group of 6 upon hearing the word spoken by the clinician (no printed stimulus)
Incorrect spoken responses that are real words are used as future stimuli.

63. TWA Treatment Data Baseline 87% 85% 95% 67% 37% 45% 43% 55% 65% 75%
10/28/13
10/30/13
11/4/13
11/6/13
11/13/13
11/22/13
12/16/13
12/20/13
12/23/13
1/3/14
1/10/14
Match written word to pic
100%
87%
85%
95%
Read word aloud
67%
37%
45%
43%
55%
65%
75%
Repeat word
83%
81%
78%
Aud. Word ID to pic
Name Picture
50%
71%
90%

64. TWA Video
Video of TWA

65. Complex Semantic Naming
Can be used as an expressive or receptive program
Study suggests patients trained on naming of atypical exemplars demonstrated generalization to naming of intermediate and typical items, but pt. trained on typical items demonstrated no generalized naming effect to intermediate or atypical examples (Kiran and Thompson 2003)
When using as a receptive treatment program you can target understanding of complex yes/no questions and semantic sorting
Example of atypical flamingo will activate untrained word crow
Vs crow activating flamingo,
Example of top down approach

66. Complex Semantic Naming
Treatment Steps
Step 1: pt. names the picture
Step 2: pt. is given 2 written choices of a category and is asked to identify which category the picture belongs in
Step 3: pt. is given 6 written semantic features (3 yes and 3 no) and then asked to identify which semantic features are yes and which are no
Step 4: pt. answers 15 yes/no questions pertaining to the semantic features of the target
Step 5: pt. names the picture again

67. Complex Semantic Naming Treatment Data
Set 2
Set 3
Select semantic feature
91%
100%
Answer y/n ques.
90%
93%
Name typical picture
80%
50%
70%
40%
10%
Mod A
Ind.
Min
Name atypical picture
60%

68. Aphasia Treatments and the chronic patient
MACDG
November 4, 2015
St. Louis, Missouri
Karen Blank M.A.CCC
Senior Speech Therapist at The Rehabilitation Institute of St. Louis
The Rehabilitation Institute of St. Louis

69. Treating the Chronic Patient
Past research studies ,from 1982(Holland) to present , have cited improvements made with the chronic aphasic patient.
Moss and Nicholas (2006) describe chronic patients as 1 year post stroke. They showed that improvements made in treatment can be made up to years post stroke.
Meinzer et al (2004) showed after intensive therapy with patients with chronic aphasia, there were positive changes in brain activity correlated to positive changes in language functions . They concluding that reorganization of the brain occurs even years after stroke.
Basso and Macis(2011) showed 9/13 chronic patients improved in oral and written nouns and action naming, and oral and written sentence production. Again, intensive therapy ,including 2-3 hours of homework ,aided in gains made.

70. Treatment Progression of the Nonfluent patient
Gestural verbal treatment /Prompt or Tactile-Kinesthetic treatments: Treating apraxia of speech with trained words and phrases ↓
2. Script training/RET training: To elicit more information and increase fluency/length of utterance.
3. Promote generalization through use with family and friends, use of “wh” questions to elicit conversationally relevant speech.

71. Treatment progression of the Fluent Patient
Treatment for Wernicke’s Aphasia (TWA)
Speech Reading/Lindamood Phonological Program ↓
Phonological Component (PCA)Analysis/ Semantic Feature Analysis (SFA)/ Complex Semantic Feature Analysis (Kiran)
3. VNESST/ Script training/ and RET training
4. Generalization: Wh-questions in conversation and continue to track LCI, content units, and efficiency.

72. Analysis of Treatment of Chronic Patients in the EBAC
From 20 chronic patients seen over the last few years in the EBAC the following were results of evidenced-based treatment. Significant change on WAB 5 points, Significant change of CETI 11 points.
Changes in WAB scores were: average of points the range was -13 to 61.3 pts
Changes in LCI scores were: average .65
Changes in Content Units were: average 1.27
Changes in CETI were from significant other were: average 11.4
Changes in CETI from pt. were: average 10.7
Average time of treatment from onset was: average 488 days ( )
Average time of treatment was: average 21 months (15-25)
Pre
Post
Significance
WAB
43.94
65.11
<.001*
LCI
.25
.91
.002*
Content Unit
2.82
4.09
.165
Efficacy
1.50
3.27
.078
CETI-Self
56.16
66.81
.064
CETI-Other
45.73
57.13
.017*

73. Statistically significant changes in the chronic patient
85% of chronic patients showed statistically significant increase in WAB from admit to discharge
54% of chronic patients family members had statistically significant increase in CETI

74. Increasing Content Units
Pt’s who increased content units by 15% or higher
Aphasia subtypes and treatments: n=6
Global: GVT
Broca’s : Lindamood → RET
Non fluent : RET
Non-fluent: Script training →PCA →RET
Wernike’s: RET
Conclusion
Increases in content units improved greatest with our non-fluent patients receiving RET.
All nonfluent patients
4/6 received RET

75. Increasing Efficiency
Pt’s whose efficiency increased by at least four content units per minute.
Aphasia subtypes and treatments: n=5
Anomic: PCA
Broca’s: Lindamood→RET
Mixed non fluent: RET
Mixed Nonfluent: TWA/Complex Semantic Naming/SFA/RET
Wernikes: RET
Conclusion:
RET worked best with this pt population to improve efficiency (4/5 received RET).
Efficiency changes seen with both fluent and nonfluent patients with both receptive and /or expressive aphasias.

76. Increasing LCI Aphasia subtypes and treatment N=8
Pt’s increasing LCI by .5 or higher
Aphasia subtypes and treatment N=8
Non-fluent: GVT→Script → VNeSST → RET
Mixed nonfluent: VNeSST
Broca’s: Lindamood →RET
Nonfluent: PROMPT →RET →VNeSST
Anomic: Script training →PCA →RET
Nonfluent: TWA →Complex Semantic Naming →SFA →RET
Transcortical Motor: RET
Mixed non fluent: Script training → RET
Conclusion:
Biggest LCI improvements were seen in the chronic patients with non fluent aphasia who were treated with RET and/or VNeSST.

77. Case Study of a EBAC Pt. with Chronic Aphasia
Pt is a 54 year old male that suffered a left CVA with severe AOS in with onset on 2012
Pt began therapy in 12/18/13 with Prompt therapy and was trained on 40 functional phrases with pt achieving 80% accuracy over 2-3 weeks. Video PROMPT Pt used these phrases in therapy and some use at home with wife and family and employees.
WH questions to assist with functional carryover video to generalize trained phrases.
Pt proceeded with RET therapy that aided use of content units in functional, everyday speech but did not improve in his LCI scores. RET video
Then pt advanced to VNESST which improved his LCI scores from 0.0 in beginning of therapy to .5 in monthly probes, and then when using wh questions for relevant topics he was interested in. Video of VNeST
Pts WAB scores at 6 month intervals were : (4/14); 51.5 (10/2014); and 64.7 (6/2015). Significant change each time after spontaneous recovery.
CETI scores by wife were lowered from 60%-50% but CETI scores by pt. went from 64 to 81% in which pt kept indicating that he continued to speak better in home and work situations.

78. Conclusions of Presentation
How are we going to find ways to deliver evidenced-based therapies in an intensive manner to chronic patients when 3rd party payers stop funding the therapy?
SLP’s should be aware of current evidence based aphasia treatments in order to determine which treatment would be most effective for their clients aphasia subtype.
Furthermore, SLP’s need a protocol (e.g. interval probes) to measure whether the treatment is improving their pt’s language.
4 . Need to set up criteria for discharge, including what goals patients want to achieve, and length of therapy.
Tune ups may be needed with chronic patients post discharge (e.g. every 6 months) to encourage ongoing recovery.
More research needed to predict language recovery post stroke and determine best care path.

79. Questions

80. References
Antonucci, S.M. (2009). Use of semantic feature analysis in group aphasia treatment. Aphasiology, 23 (7-8),
Bose, A., Square, P. A., Schlosser, R., & van Lieshout, P. (2001).Effects of PROMPT therapy on speech motor function in a person with aphasia and apraxia of speech. Aphasiology, 15(8), 767–785.
Basso, A; Macis, M.;Therapy Efficacy in Chronic Aphasia. Behavioral Neurology; 2011
Boyle, M. (2004). Semantic feature analysis treatment for anomia in two fluent syndromes. American Journal of Speech-Language Pathology, 13,
Boyle, M., & Coelho, C.A. (1995). Application of semantic feature analysis as a treatment for aphasic dystonia. American Journal of Speech-Language Pathology, 4,
Conley, A., & Coelho, C. (2003). Treatment of word retrieval impairment in chronic Broca’s aphasia. Aphasiology, 17(3),
Helm-Estabrooks, N., Fitzpatrick, P., & Barresi, B. (1982). Visual Action Therapy for Global Aphasia. Journal of Speech and Hearing Disorders, 47,
Holland, A, ; Aten, James L.;Caliguiri, M.; The Efficacy of Functional Communication Therapy for Chronic Aphasia Patients. Journal of Speech and Hearing Disorders, Feb. 1982, Vol 47, 93-96
Leonard, C., Rochon, E., and Laird, L. (2008). Treating naming impairments in aphasia: Findings from a phonological components analysis treatment. Aphasiology, 22(9),

81. References
Lowell, S., Beeson, P.M., & Holland, A.L. (1995). The efficacy of a semantic cueing procedure on naming abilities of adults with aphasia. American Journal of Speech-Language Pathology, 4,
Meiner, M.; Elbert, T. Weinbruch, C; Dundja, D., Barthal, G.; Rockstroh, B.; Intensive Language Training Enhances Brain Plasticity in Chronic Aphasia. BMC Biology, 2004.
Moss, A. Nicholas, M. Language Rehabilitation in Chronic Aphasia and Time Postonset. Stroke 2006
Naeser, M; Martin, P; Nicholas, M; Baker, E.; Improved Picture Naming in Chronic Aphasia after TMS (transcranial magnetic stimulation) to part of right Broca’s Area: An Open Protocol Study. Brain and Language; Vol. 93 April, 2005, pg
Peach, R.K., & Reuter, K.A. (2010). A discourse-based approach to semantic feature analysis for the treatment of aphasic word retrieval failures. Aphasiology, 24 (9),
Kiran, S., & Thompson, C.K. (2003). The role of semantic complexity in treatment of naming deficits: Trainng semantic categories in fluent aphasia by controlling exemplar typicality. Journal of Speech, Language and Hearing Research, 46,
Rodriguez, A., Raymer, A., & Gonzalez Rothi, L. (2006). Effects of gesture+verbal and semantic‐phonologic treatments for verb retrieval in aphasia. Aphasiology, 20,
Wambaugh, J. (2013). Semantic Feature Analysis: Incorporating Typicality Treatment and Mediating Strategy Training to Promote Generalization. American Journal of Speech-Language Pathology, 22,
Youmans, G., Holland, A., Munoz, M., & Bourgeois, M. (2005). Script training and automaticity in two individuals with aphasia. Aphasiology, 19,
Holland, A., Milman, L., Munoz, M., & Bays, G. (2002). Scripts in the management of aphasia. Paper presented at the World Federation of Neurology, Aphasia and Cognitive Disorders Section Meeting, Villefranche, France.