Complexity and Feedback During Script Training in Aphasia: A Feasibility Study

  • Leora R. Cherney
    Corresponding author Leora R. Cherney, PhD, CCC-SLP, BC-ANCDS, FACRM, Shirley Ryan AbilityLab, 355 East Erie St, Chicago, IL 60611.
    Center for Aphasia Research and Treatment, Shirley Ryan AbilityLab, Chicago, Illinois

    Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois

    Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois
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  • Sarel Van Vuuren
    Institute of Cognitive Science, University of Colorado Boulder, Boulder, Colorado, United States
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Published:March 15, 2022DOI:



      To explore the effect of complexity and feedback on script training outcomes in aphasia


      Randomized balanced single-blind 2 × 2 factorial design.


      Freestanding urban rehabilitation hospital.


      Adults with fluent and nonfluent aphasia (at least 6 months post onset).


      Experimental treatment was AphasiaScripts, a computer-based script training program. Scripts were 10-turns long and developed at different complexity levels to allow for comparison of high vs low complexity. The program was modified to contrast high vs low feedback conditions during sentence practice. Participants were instructed to practice three 30-minute sessions per day, 6 days per week for 3 weeks.

      Main Outcome Measures

      Gains achieved from baseline in accuracy and rate of production of trained and untrained script sentences at post treatment and at 3-, 6-, and 12-weeks after the end of treatment.


      Sixteen participants completed the intervention. On the trained script, gains were statistically significant for both accuracy and words per minute at post treatment and 3-, 6-, and 12-week maintenance. Gains on the untrained script were smaller than on the trained script; they were statistically significant only for accuracy at post treatment and 3-week maintenance. Complexity had an influence on accuracy at post-treatment (F1=4.8391, P=.0501) and at maintenance (F1=5.3391, P=.0413). Practicing scripts with high complexity increased accuracy by 11.33% at post treatment and by 9.90% at maintenance compared with scripts with low complexity. Participants with nonfluent aphasia made greater gains than those with fluent aphasia. There was no significant effect of feedback.


      This study reinforces script training as a treatment option for aphasia. Results highlight the use of more complex scripts to better promote acquisition and maintenance of script production skills. There is a need for further investigation of these variables with larger samples and with other types of aphasia treatments.


      List of abbreviations:

      AQ (Aphasia Quotient), SE (speech entrainment), WAB-R (Western Aphasia Battery-Revised), wpm (words per minute)
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        • Simmons-Mackie N.
        Aphasia in North America: frequency, demographics, impact of aphasia, communication access, services and service gaps.
        AphasiaAccess, Moorestown, NJ2018
        • Brady MC
        • Kelly H
        • Godwin J
        • Enderby P
        • Campbell P.
        Speech and language therapy for aphasia following stroke.
        Cochrane Database Syst Rev. 2016; 6CD000425
        • Cherney L
        • Small S
        Aphasia, apraxia of speech, and dysarthria.
        in: Stein J Harvey R Winstein C Zorowitz R Wittenberg GF stroke recovery and rehabilitation. Demos Medical Publishers, New York2015: 181-206 (editors)
        • Maier M
        • Ballester BR
        • Verschure P.
        Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms.
        Front Syst Neurosci. 2019; 13: 74
        • Thompson CK
        • Ballard KJ
        • Shapiro LP.
        The role of syntactic complexity in training wh-movement structures in agrammatic aphasia: optimal order for promoting generalization.
        J Int Neuropsychol Soc. 1998; 4: 661-674
        • Ballard KJ
        • Thompson CK.
        Treatment and generalization of complex sentence production in agrammatism.
        J Speech Lang Hear Res. 1999; 42: 690-707
        • Thompson CK
        • Shapiro LP
        • Kiran S
        • Sobecks J.
        The role of syntactic complexity in treatment of sentence deficits in agrammatic aphasia: the complexity account of treatment efficacy (CATE).
        J Speech Lang Hear Res. 2003; 46: 591-607
        • Thompson CK
        • Shapiro LP.
        Complexity in treatment of syntactic deficits.
        Am J Speech Lang Pathol. 2007; 16: 30-42
        • Kiran S.
        Complexity in the treatment of naming deficits.
        Am J Speech Lang Pathol. 2007; 16: 18-29
        • Kiran S
        • Johnson L.
        Semantic complexity in treatment of naming deficits in aphasia: evidence from well-defined categories.
        Am J Speech Lang Pathol. 2008; 17: 389-400
        • Kiran S.
        Typicality of inanimate category exemplars in aphasia treatment: further evidence for semantic complexity.
        J Speech Lang Hear Res. 2008; 51: 1550-1568
        • Gierut JA.
        Phonological complexity and language learnability.
        Am J Speech Lang Pathol. 2007; 16: 6-17
        • Murray LL
        • Holland AL
        • Beeson PM.
        Accuracy monitoring and task demand evaluation in aphasia.
        Aphasiology. 1997; 11: 401-414
        • McKissock S
        • Ward J.
        Do errors matter? Errorless and errorful learning in anomic picture naming.
        Neuropsychol Rehabil. 2007; 17: 355-373
        • Bilda K.
        Video-based conversational script training for aphasia: a therapy study.
        Aphasiology. 2011; 25: 191-201
        • Cherney LR
        • Halper AS
        • Holland AL
        • Cole R.
        Computerized script training for aphasia: preliminary results.
        Am J Speech Lang Pathol. 2008; 17: 19-34
        • Lee JB
        • Kaye RC
        • Cherney LR.
        Conversational script performance in adults with non-fluent aphasia: treatment intensity and aphasia severity.
        Aphasiology. 2009; 23: 885-897
        • Goldberg S
        • Haley KL
        • Jacks A.
        Script training and generalization for people with aphasia.
        Am J Speech Lang Pathol. 2012; 21: 222-238
        • Youmans G
        • Holland A
        • Munoz M
        • Bourgeois M.
        Script training and automaticity in two individuals with aphasia.
        Aphasiology. 2005; 19: 435-450
        • Hubbard HI
        • Nelson LA
        • Richardson JD.
        Can script training improve narrative and conversation in aphasia across etiology?.
        Semin Speech Lang. 2020; 41: 99-124
        • Manheim LM
        • Halper AS
        • Cherney L.
        Patient-reported changes in communication after computer-based script training for aphasia.
        Arch Phys Med Rehabil. 2009; 90: 623-627
        • Cherney LR
        • Halper AS
        • Kaye RC.
        Computer-based script training for aphasia: emerging themes from post-treatment interviews.
        J Commun Disord. 2011; 44: 493-501
        • Cherney LR.
        Aphasia treatment: intensity, dose parameters, and script training.
        Int J Speech Lang Pathol. 2012; 14: 424-431
        • Cherney LR
        • Kaye RC
        • Lee JB
        • van Vuuren S.
        Impact of personal relevance on acquisition and generalization of script training for aphasia: a preliminary analysis.
        Am J Speech Lang Pathol. 2015; 24: S913-S922
        • Cherney LR
        • Braun EJ
        • Lee JB
        • Kocherginsky M
        • Van Vuuren S.
        Optimising recovery in aphasia: learning following exposure to a single dose of computer-based script training.
        Int J Speech Lang Pathol. 2019; 21: 448-458
        • Cherney LR
        • Kaye RC
        • van Vuuren S.
        Acquisition and maintenance of scripts in aphasia: a comparison of two cuing conditions.
        Am J Speech Lang Pathol. 2014; 23: S343-S360
        • Kertesz A.
        Western Aphasia Battery (revised).
        PsychCorp, San Antonio2007
        • Kaye RC
        • Cherney LR.
        Script templates: a practical approach to script training in aphasia.
        Top Lang Disord. 2016; 36: 136-153
        • Kincaid JP
        • Fishburne RP
        • Rogers RL
        • Chissom BS.
        Derivation of new readability formulas (Automated Readability Index, Fog Count, and Flesch Reading Ease formula) for Navy enlisted personnel. Research branch report 8-75, Chief of Naval technical training.
        Naval Air Station, Memphis1975
        • Pitts LL
        • Hurwitz R
        • Lee JB
        • Carpenter J
        • Cherney LR.
        Validity, reliability and sensitivity of the NORLA-6: naming and oral reading for language in aphasia 6-point scale.
        Int J Speech Lang Pathol. 2018; 20: 274-283
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        Laurence Erlbaum and Associates, Hillsdale, NJ1988
        • Schwartz MF
        • Middleton EL
        • Brecher A
        • Gagliardi M
        • Garvey K.
        Does naming accuracy improve through self-monitoring of errors?.
        Neuropsychologia. 2016; 84: 272-281
        • Fridriksson J
        • Hubbard HI
        • Hudspeth SG
        • et al.
        Speech entrainment enables patients with Broca’s aphasia to produce fluent speech.
        Brain. 2012; 135: 3815-3829
        • Fridriksson J
        • Basilakos A
        • Hickok G
        • Bonilha L
        • Rorden C.
        Speech entrainment compensates for Broca's area damage.
        Cortex. 2015; 69: 68-75
        • Bonilha L
        • Hillis AE
        • Wilmskoetter J
        • et al.
        Neural structures supporting spontaneous and assisted (entrained) speech fluency.
        Brain. 2019; 142: 3951-3962
        • Feenaughty L
        • Basilakos A
        • Bonilha L
        • Fridriksson J.
        Speech timing changes accompany speech entrainment in aphasia.
        J Commun Disord. 2021; 90106090