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The novel language-systematic aphasia screening SAPS: Screening-based therapy in
combination with computerised home-training
Franziska Krzok1, Verena Rieger1, Katharina Niemann1, Ruth Nobis-Bosch2, Irmgard Radermacher1,
Walter Huber1, Klaus Willmes1, Stefanie Abel1,3
1 Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
2 Section of Continuous Learning, German Association of Logopedics (dbl), Germany
3 Neuroscience and Aphasia Research Unit, Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, UK
Correspondence to:
PD Dr. Stefanie Abel,
Neuroscience and Aphasia Research Unit (NARU),
School of Biological Sciences,
University of Manchester,
Brunswick Street, Manchester, M13 9PL, UK
E-mail: [email protected]
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The novel language-systematic aphasia screening SAPS: Screening-based therapy in
combination with computerised home-training
Background: SAPS is a novel language-systematic aphasia screening developed for the German language, which
already had been positively evaluated. It offers a fast assessment of modality-specific psycholinguistic
components at different levels of complexity and the derivation of impairment-based treatment foci from the
individual performance profile. However, the SAPS has not been evaluated in combination with the new SAPS-
based treatment yet.
Aims: We set out to replicate the practicality of the SAPS and investigate the effectiveness of a SAPS-based face-
to-face therapy combined with computerised home-training in a feasibility study. We aimed to examine the
soundness of the treatment design, to determine treatment-induced changes in patient performance as measured
by the SAPS, to assess parallel changes in communicative abilities, and to differentiate therapy effects achieved
by face-to-face therapy versus add-on effects achieved by later home-training.
Methods and Procedures: 16 participants with post-stroke aphasia (PWA) were included into our study. They
were administered the SAPS and communicative testing before and after the treatment regimen. Each PWA
received one therapy session followed by home-training per day, with the individual treatment foci being
determined according to initial SAPS-profile, and duration of treatment and possible change of focus dependent
on performance assessed by continuous therapy monitoring.
Outcomes and Results: The combination of therapy and home-training based on the SAPS was effective for all
participants. We were able to show significant improvements for impairment-based SAPS performance and, with
high inter-individual variability, in everyday communication. These two main targets of speech and language
therapy were correlated and SAPS-improvements after therapy were significantly higher than after home-training.
Conclusions: The SAPS offers the assessment of an individual performance profile in order to derive sufficiently
diversified, well-founded and specific treatment foci and to follow up changes in performance. The appending
treatment regimen has shown to be effective for our participants. Thus, the study revealed feasibility of our
approach.
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Keywords: Aphasia, Speech and Language Therapy, Language processing, Neuropsychology, Diagnosis
What is already known: The efficacy of aphasia therapy in the chronic recovery stage previously has been confirmed and
various diagnostic instruments are available to assess language performance and its therapy-related changes. However,
there is no standardised aphasia test that, in one go, covers the multitude of language-systematic impairments and directs
subsequent therapy. To fill this gap, the language-systematic aphasia screening SAPS has been developed for the German
language, but it has not been not been evaluated in combination with the new SAPS-based treatment yet.
What this study adds: We were able to show that the SAPS and its appending treatment regimen are feasible. SAPS offers a
sufficiently diversified, well-founded and specific guidance on the choice of treatment foci and allows the assessment of
treatment-induced changes in performance. The treatment regimen consisting of SAPS-based therapy and home-training was
effective for our patient group: We found significant improvements for impairment-based SAPS performance and for everyday
communication. Thus, the SAPS-based treatment approach is feasible and offers a solid basis for larger treatment studies.
Clinical implications: SAPS is a novel diagnostic instrument which allows the assessment of language-systematic impairments
for clinical practice of Speech and Language Therapy. The screening offers a rationale for selection of therapy foci, and thereby
can serve as starting point for therapy planning; the SAPS-based therapy integrates home-training into the therapy regimen, and
changes in performance can be tightly monitored. In rehabilitation settings, the SAPS may prove to be an important complement
to current assessment and treatment of aphasia.
Introduction
The efficacy of aphasia therapy has been confirmed in numerous studies (Brady et al. 2016, Breitenstein et al. 2017).
It is well-known that therapy leads to the most favourable outcomes when delivered at high frequency (Bhogal et al.
2003b, Brady et al. 2016) and in short but intensive intervals (Bhogal et al. 2003a). With intensive aphasia therapy,
not only persons with aphasia (hereinafter referred to as PWA) in the acute stage of aphasia, but also those in the
chronic stage can achieve further improvements (Rose et al. 2013) – although the latter might be limited and smaller
than those gained during the earlier recovery stages which are assisted by spontaneous improvements (Basso and
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Macis 2011). In order to deliver high-dose aphasia therapy and maximise intensity, computer-based home-training
can supplement face-to-face therapy. The integration of computer training into a treatment regimen has shown to be
effective (Allen et al. 2012, Stark and Warburton 2016, Stachowiak 1993, van de Sandt-Koenderman 2011, Zheng et
al. 2016).
While the efficacy of aphasia therapy in general is evident, it remains relatively unresolved which therapy
method to choose for an individual PWA in order to obtain optimal therapy outcomes, and the exact intensity and
dose required to reach this outcome. According to the International Classification of Functioning, Disability and
Health (ICF; World Health Organization [WHO], 2001), the superior aim of aphasia therapy is to enable each PWA
to communicate in everyday life (Springer 2008, Weniger and Springer 2006, Worrall et al. 2011). Cognitive-
linguistic therapies have been recommended as a Practice Standard for the rehabilitation of language and
communication deficits, with the approach favourably being accompanied by participation-based approaches aiming
at amelioration of pragmatic communication and conversational skills, and potentially being assisted by supervised
computer-based training (Cicerone et al. 2000). A standardised aphasia test that, in one go, covers the multitude of
language-systematic impairments and directs subsequent therapy would be of high value. Moreover, the inclusion of
computer-based training into the impairment-based treatment regimen would be desirable, and some positive effects
on communicative performance would be expected even though not directly practiced. The current therapy approach
based on the German test instrument “Sprachsystematisches Aphasiescreening (SAPS)” (Blömer et al. 2013; SAPS
was initially translated as Speech-systematic Aphasia Screening, but was relabelled to Language-Systematic Aphasia
Screening to gain English unambiguousness) was developed to fill this significant gap.
The efficacy of aphasia therapy can be assessed using standardised diagnostic instruments. In Germany,
various language-systematic tests enable the evaluation of speech and language therapy for lexical and sub-lexical
disorders (e.g., LeMo: de Bleser et al. 2004, Hierarchische Wortlisten: Liepold et al. 2003). The ICF has underlined
the necessity to also disclose to what extent PWA can participate in everyday life and what impact aphasia therapy
exerts on participation. To ascertain whether the ultimate speech and language therapy (SLT) goal to improve
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communicative abilities has been reached requires other diagnostic instruments than those which describe
improvement of underlying linguistic functions (Blomert 1990). Although participation-based diagnostic instruments
for assessment of everyday communication are rare, there is the Amsterdam-Nijmegen Everyday Language Test
(ANELT; Blomert et al. 1994, Blomert et al. 1987). This test (primarily) measures the ability to convey information
verbally in everyday situations, while the linguistic form of the message is of minor importance. For any new
language-systematic diagnostic instrument, information about its relation to participation-based measures is
mandatory.
While there are various diagnostic instruments for aphasia, to our knowledge none of them offers sufficiently
diversified, well-founded and specific guidance on the choice of therapy. For the Dutch language, ScreeLing (Visch‐
Brink et al. 2010) assesses sub-lexical, lexical and syntactic language components and thereby gives a short
overview. For the German language, Abel et al. (in preparation) developed the SAPS (see Blömer et al. 2013) whose
rationale to directly derive foci for aphasia treatment is to be further examined in the present study. Before study
initiation, it was unclear how best to choose individual treatment foci from a given SAPS performance profile, and
how much time to dedicate to each chosen focus given the restricted time frame for therapy deliverance. While the
former was considered to depend on locus and severity of impairment and affect therapy outcomes, the latter was
considered to depend on individual speed of learning and to affect time to reach mastery level per treatment focus.
Thus, in the present feasibility study, therapists were instructed to (1) freely choose two affected language
functions within the SAPS scheme at a time, (2) monitor and treat the trained items of the therapy foci chosen, using
SAPS-tasks (including appending home-training), (3) complement therapy with any SLT procedure and materials
deemed appropriate for the individual PWA and foci, and (4) comply with pre-defined sequences of item sets, based
on individual learning speed as assessed in the monitoring. Thus, the therapy design is both strict and flexible, also
allowing to assess its soundness and carve out an optimal rationale for the selection of therapy foci within the SAPS.
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Overview of the SAPS (language-systematic aphasia screening)
The SAPS assesses the three different linguistic domains phonology/phonetics (sublexical functions),
lexicon/semantics (lexical functions) and morphology/syntax (morpho-syntactic functions) in both receptive and
expressive language modalities (see Figure 1 for an overview). Each of the six resulting modules on the horizontal
axis consists of three cells (language tasks) with different levels of demand on the vertical axis. Thus, taken as a
whole the SAPS comprises 18 cells, i.e. 18 different language tasks which can be selected as treatment foci for
therapy and home-training. While the SAPS covers the core language domains of phonology, lexicon, and syntax
with their ancillary components for both receptive and expressive spoken modalities, it does not assess performance
for written language or more complex text/discourse processing. The compilation of SAPS tasks with appendent
treatment regimen was founded on established knowledge on the components of language processing (especially the
Levelt model; overviews in Brown and Hagoort 2000, Hillis 2015) and evidence-based best practice in SLT (e.g.,
Cicerone et al. 2000, Hillis 2015, Brady et al. 2006) as also applied at the Aachen Aphasia Ward, a special aphasia
unit for intensive speech therapy and neuropsychological treatment for stroke patients since 1984 (Huber et al. 1999)
where the present study was conducted.
- Figure 1 about here -
The assessment with the present SAPS version is performed via computer. The SLT evaluates the responses
of the PWA online using keyboard keys, and the computer presents a summed score at the end of each cell. The
output of the screening is an individual performance profile, identifying linguistic strengths and weaknesses of each
PWA. Based on this profile, the language-systematic and controlled therapy can be planned and executed. By
focusing treatment at the impaired task (cell), the goal of improving the according linguistic function and underlying
processing stages is implied (Figure 1), with the broader goal of accomplishing generalisation to other items and tasks
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as well as translation to everyday language. The face-to-face SAPS therapy is complemented by a computer-based
home-training, for both of which half of the test items (Training items or T-items, N=12 for receptive and N=8 for
expressive cells) can be used in SAPS-tasks. The remaining items (Control items or C-items; also N=12 and N=8 for
receptive and expressive cells, respectively) are reserved for assessments only (further information about the choice
of treatment foci and SAPS-based therapy are given in the methods section).
In 2013, Blömer et al. evaluated the original version of the SAPS. By and large, the properties of the test
construction currently were confirmed for the present sample, and the tasks which were insufficiently graded in
difficulty were successfully revised, yielding high internal consistency in all modules (Cronbach’s alpha >.90) and an
appropriate gradation in difficulty according to the levels of demand for the modified SAPS. The current feasibility
study built the basis for a larger aphasia trial (Breitenstein et al. 2017), and the successful final test construction and
evaluation will be addressed elsewhere using this larger sample.
Aims and hypotheses of the present study
In the present pilot study, we investigated aphasia therapy based on the final, revised version of the SAPS (language-
systematic aphasia screening). We aimed to determine the modules/cells chosen for treatment (therapy and home-
training) and the impact of speed of learning in the group of PWA as featured by our treatment design, to examine its
soundness. We hypothesised that (hypothesis 1) our treatment approach which consists of SAPS-based therapy and
computer-based home-training resulted in improvements in PWA’s performance in the SAPS modules chosen, (2)
home-training led to further improvements in PWA’s performance over and above face-to-face therapy, (3) home-
training was well-constructed and feasible, and (4) language-systematic treatment affected communicative
performance as measured in a participation-based language test (ANELT).
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Methods
Experimental design
The study was conducted on the Aachen Aphasia Ward at the RWTH Aachen University Hospital, where PWA
receive multidisciplinary, complex and high-intensity SLT as in-patients for typically 7 weeks, usually covered by the
German health system (https://www.ukaachen.de/kliniken-institute/klinik-fuer-neurologie/klinik/aphasiestation.html).
The design of the study is presented in Figure 2. In week 1, PWA were pre-tested with SAPS and ANELT. As a
current assessment with the Aachen Aphasia Test (AAT; Huber et al., 1983) is a prerequisite for admission to the
ward, those scores were also available for each PWA. After that, each PWA received treatment for up to 16
consecutive weekdays. Subsequent to the treatment phase, the PWA were assessed with SAPS and ANELT again.
After termination of the study regimen, they received further intensive standard therapy for their remaining stay on
the ward. Therefore, we did not re-assess the PWA in a follow-up. Test results are shown in Supplementary Table S2
(SAPS), S3 and S4 (AAT), and S5 (ANELT).
- Figure 2 about here -
Language Assessment
The SAPS as implemented in the computer software Presentation by the senior author (version 0.70, 09.02.03) was
carried out on a laptop at both test times. In the computer-based SAPS version, the Speech and Language Therapist
(SLT) scored the responses of the PWA via coded button responses online. The computer automatically counted and
summed the scores reached by the PWA in real-time, assessed whether the PWA met pre-defined criteria for
termination of each cell/module, delivered summaries of scores, and determined the performance categories. The
PWAs’ outcome for each cell was attributed to three different performance categories, resulting in an individual
performance profile (see Figure 3 for an example). Based on the maximum scores of the cells and a confidence level
of 95% according to the binomial model (Willmes, 2000), the categories were calculated separately for receptive (24
8
items, max. 48 points) and expressive (16 items, max. 64 points) cells: “mastered” (≥90% correct according to the
binomial model), “mastered with uncertainties” (≥75%), and “not mastered” (<75%); assessment along the increasing
levels of demand per module could be terminated as soon as non-mastery of a cell became evident.
Embedded within clinical routine, SAPS pre-tests and therapy were carried out by one of the experienced
speech therapists from the aphasia ward, and SAPS post-tests were conducted by the authors who were blind to
treatment foci chosen (K. Niemann, V. Rieger and F. Krzok performed testing as SLT master students, supervised by
S. Abel, W. Huber and K. Willmes as experienced clinicians in aphasiology). For the repeated assessment with the
ANELT, we used its version A for pre-testing and version B for post-testing. The ANELT assessments were also
carried out by the authors as stated above, with pre- and post-test not being conducted by the same examiner.
- Figure 3 about here -
Participants
Within an interval of 5 months, we recruited in-patients from the Aachen Aphasia Ward. Persons with (i) post-acute
or chronic aphasia (≥ 6 months post-onset) (ii) of vascular genesis, (iii) with suitability for language-systematic
training and (iv) a stay at the ward for full 7 weeks were considered for inclusion. Moreover, (v) good comprehension
of task instructions (i.e., reasonable responses to tasks, e.g. for SAPS practice items), and (vi) at least two not
mastered cells in the SAPS pre-test were a prerequisite for final inclusion. Persons with progressive speech and
language disorders, a severe apraxia of speech, or other disorders which were not covered by our study but needed to
be prevailingly addressed in therapy, rendering language-systematic therapy not suitable (e.g., severe neuro-cognitive
impairments, participation-based treatment focus requested), were excluded. Figure 4 gives an overview of the
recruitment process with our inclusion/exclusion criteria. The characteristics of all 16 PWA included into the study
are presented in Table 1. The study was approved by the ethics committee at the Medical Faculty of the RWTH
Aachen University (EK 089/17).
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- Figure 4 about here -
- Table 1 about here -
Construction of the home-training
The novel SAPS home-training featured supervised, self-guided computer-based training (Power Point Presentation,
Office 2003, Windows XP) covering all SAPS-tasks. The T-items of each SAPS cell were divided into two parallel
sets (set A and set B), rendering 36 presentations for home-training. All presentations were designed equally so PWA
could easily recognize recurring elements of the home-training. To keep handling as easy as possible, each home-
training presentation was kept visually and cognitively simple without distracting elements.
The home-training aimed at multi-modal stimulation of target tasks and items within five levels: three initial
stimulation levels, a consecutive level with SAPS-demands, and a final drill level. The stimulation levels either
offered some preparatory training to prime the target task/items or consisted of the target SAPS-task with additional
cues, modalities and feedback for the according items. On level 4, the PWA performed the task exactly as demanded
in SAPS, without further assistance. All in all, in the course of stimulation the cues vanished and the demands
increased. Each item passed through levels 1-4 before being repeatedly practiced at the drill level with SAPS
demands amongst all other items and in varying order. An example of the home-training (lexical-receptive cell,
easiest level of demand) is shown in in Supplementary Figure S3. The SAPS-tasks for this cell constitutes auditory
word-to-picture matching: On stimulation levels 1-3, the number of distractors is limited, and PWA can repeatedly
listen to the target item which is presented simultaneously in written modality.
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SAPS-based treatment: face-to-face therapy in combination with home-training
One hour of SAPS-based therapy and one hour of home-training were performed each weekday, summing up to two
hours SAPS-treatment per weekday. For home-training, we supervised every home-training of a new cell, which
might result in up to three supervised sessions per week. SAPS-based therapy was conducted by SLTs from the ward,
who were experienced in impairment-based therapy for aphasia, and they received advise by S. Abel, W. Huber and
K. Willmes in case of any uncertainty. Based on the performance profile derived from the pre-test, the SLT decided
autonomously which foci to work on in therapy and chose two cells, which needed to be either not mastered or
mastered with uncertainties, as starting point for treatment. For SAPS-based therapy, the T-items of the chosen
SAPS-cells were trained using the according SAPS-tasks, and further materials and therapy tasks of similar demands
and structure could complement the approach at the discretion of the SLT, if time allowed. The same SAPS-items
used in therapy were trained during home-training, with each session taking about an hour and each of the two cells
occupying about half of each session. Training success was monitored by assessing performance for the SAPS-items
in the according task at the beginning and end of each one-to-one therapy session; the development of scores from
initial versus final monitoring of the same session was taken to reveal therapy effects, while those from final
monitoring of a session versus initial monitoring of the following session was supposed to reveal home-training
effects. If performance criteria were reached after two days of treatment as registered in initial monitoring of a
session (indicating fast learning for that cell) or after four days (indicating moderate or slow learning), a new
treatment focus was chosen (see also Figure 2). This procedure continued until 16 therapy days had been completed
or no more cells were left to choose from. An overview of the three types of learning as featured in the SAPS-design
is presented in Figure 5. There are three possible versions of progression along treatment days with varying set
sequences which are dependent on a PWA’s learning speed. Since there is only little evidence in the literature on
how often item (sets) need to be repeated until PWA master a certain level of demand, we chose a procedure which is
both simple for the SLT to conduct and flexible to adapt it to individual learning curves, and which allows us to
investigate this issue further. Our approach ensured that PWA could improve in as many cells as possible dependent
on their learning curves (limited by the maximum therapy duration of 16 days), and therefore cover different
11
treatment foci without having a drill effect from overly repeating the relatively small item set of a cell too often (a full
demonstration with criteria for progression is shown in Supplementary Table S1).
- Figure 5 about here -
The current SAPS-based treatment replaced the regular one-to-one therapy plus homework on the ward.
Please note that over and above obligatory group therapies (3x/week), PWA were still able to additionally attend low-
frequent offers at the ward, including music therapy or computer-based therapy. On the ward, the individualised
computer-based therapy did not cover SAPS-items, -task or -demands, and any task similar to SAPS was omitted in
computer-based therapy; instead, PWA focused on writing, internet searches, and the creation of presentations.
Moreover, the SLT had the opportunity to integrate other therapy goals such as writing or basic exercises (e.g. for
apraxia of speech) in the SAPS-therapy. However, it did not exceed the particular SAPS-demand or involve C-items.
Statistical analyses
For the statistical data evaluation we used SPSS Statistics 20 (IBM Corporation, 2011). We generally chose a
stricter threshold (p<.05) for group analyses with many items, and a more liberal threshold for analyses of limited
power, i.e. on the single case level or with fewer items involved. For our first aim and hypothesis on chosen treatment
foci and their effects we conducted group and single case analysis. On the group level, we calculated the performance
changes in the SAPS for all cells and modules as well as for the trained and untrained cells (exact Wilcoxon signed-
rank test, one-tailed, p<.05). Furthermore, we compared the performance changes between trained and untrained cells
(exact Mann-Whitney-U-test, one-tailed, p <. 05, Bonferroni-Holm corrected).
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In order to investigate the impact of learning speed, we compared performance change in relation to type of
learning (exact Mann-Whitney-U-test, one-tailed, p<.05, Bonferroni-Holm corrected) in case previous tests (Kruskal-
Wallis-test, Jonckheere-Terpstra-test for monotone trends, one-tailed, p<.05) revealed trends per cells/modules. We
also correlated the extent of performance change and the amount of trained cells with the learning speed (Spearman
rank correlation, one-tailed, p<.05). We also examined possible differences in performance change for fast learners
(fast learning in ≥75% of the cells) compared to moderate/slow learners (exact Mann-Whitney-U-test, one-tailed,
p<.05, Bonferroni-Holm corrected). Furthermore, we correlated the percentage of fast learned cells and the
percentage of successfully completed cells with the performance changes in the SAPS (Spearman rank correlation,
one-tailed, p<.05). Finally, we used cross tables in order to consider initial performance over and above the impact of
training.
On the single case level we analysed the performance change for all items as well as for T-items and C-items
separately (exact Wilcoxon signed-rank test, one-tailed, p<.10). Moreover, differential changes for T- versus C-items
were examined (exact Mann-Whitney-U-test, one-tailed, p<.10).
Furthermore, we wanted to assess various factors that might influence the outcome. To investigate the
influence of the type of aphasia (fluent vs. non-fluent) and apraxia of speech on SAPS baseline performance and pre-
post changes in the expressive modules we used exact Mann-Whitney-U-tests (one-tailed, p<.05, Bonferroni-Holm
corrected). In the same way we compared baseline performance and changes in SAPS-performance along the three
recovery stages of aphasia. For revealed trends (Kruskal-Wallis-test, Jonckheere-Terpstra-test for monotone trends,
one-tailed, p<.05) we expected improvements to decrease with time post-stroke. We also investigated possible
monotone trends (expected: post-acute > early chronic > late chronic) related to extent and success of learning,
considering the number of learned cells, fast learned cells, successfully completed cells, and type of learning per
module.
In our second and third hypothesis we focused on the home-training. Therefore we assessed the learning
progress for therapy and home-training by calculating the difference between scores for initial and final therapy
13
monitoring within and between sessions. These differences were further analysed for all PWA (n=16) on the group
level (exact Wilcoxon signed-rank test, one-tailed, p<.10).
Communicative performance was addressed in our fourth hypothesis. We determined changes for the ANELT
along critical differences from Kawalla (2011) (+/- 7 points for scale A; +/- 4 points for scale B) and correlated data
from ANELT and SAPS (Spearman rank correlations, one-tailed, p<.05)
Results
Examination of soundness of treatment design
Choice of treatment foci. Table 2 shows how many cells mastered with uncertainties or not mastered during pre-
testing were chosen for therapy. If a PWA revealed uncertainties in a cell of the phonological-receptive or lexical-
expressive module, it was always chosen. All other imperfectly mastered modules were selected at lower frequencies,
as were those with non-mastered performance levels. While the syntactic-receptive module was regularly (>80%)
chosen if at all applicable for therapy, both lexical modules were regularly selected if not mastered; syntax-
expressive was chosen at lowest rates (41%). For completely not mastered modules, mostly the two lower levels of
demands (1 or 2) were chosen.
- Table 2 -
Based on these results, we further investigated the importance of modules as treatment foci: all but one PWA
received lexical training, in particular in the expressive modality. Moreover, the initial treatment foci regularly
combined a receptive and an expressive cell. In terms of the modalities, there was a trend for selection of receptive
14
cells prior to expressive cells in the phonological, but not in the lexical or syntactic domain, and receptive cells were
generally trained more often. An overview of the chosen cells for each PWA is shown in Supplementary Figure S1.
Types of learning. Due to the high variability of performance profiles at pre-testing, the number of treatment
days varied from 6 to 16 days (see Supplementary Table S2 for individual SAPS test scores). Our analysis of the
learning progress as measured by monitoring showed that, across all modules, more cells were finished after two
rather than four days of training. On average, the PWA completed 73% of the treatment foci with fast learning.
Whereas fast learning was always completed successfully, this was not obligatory for moderate and slow learning. On
average, 85% (range: 50-100%) of cells were finished successfully, while an unsuccessful termination of cells
occurred more often in expressive (15 cells in nine PWA) than receptive modules (3 cells in two PWA).
Changes in performance for PWA
Group analysis. The treatment regimen was effective for nearly all domains and cells of the SAPS (exact Wilcoxon
signed-rank test, one-tailed, p < .05), as illustrated in Figures 6 and 7, as well as Supplementary Table S6.
- Figure 6 and Figure 7 about here -
Moreover, Supplementary Table S6 shows that eight cells revealed a training effect indicated by significantly
higher pre-post changes if the cells were trained compared to not trained (Mann-Whitney U Test, one-tailed,
Bonferroni-Holm corrected, p <. 05). Considering each module separately, we found a similar pattern (see Table 3):
If a module was chosen for treatment, there were proportionally more significant improvements than without training.
For phonological and syntactic modules, the percentage ranged from 54 to 70%; in the lexical -receptive module half
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of the trained cells improved significantly from pre- to post-test, and with a percentage of 27% the lexical- expressive
module revealed the most modest effect.
- Table 3 about here -
Table 4 shows the correlation between extent of change and training per module. It demonstrates that the more
cells the PWA trained and the faster they learned, the larger the improvements in the expressive phonological and
both syntactical modules (Spearman rank correlation, one-tailed, p < .01). Please note that for the syntactic- receptive
module, we found both improvements and deteriorations as depicted in Figure 6. Nevertheless, there was no
substantial difference in performance change when comparing fast or moderate/slow learners as a group (exact Mann-
Whitney-U-test, one-tailed).
- Table 4 about here -
Single case analysis. We found significant improvements in PWA performance for all modules (exact Wilcoxon
signed-rank test, one-tailed, p<.01 and p<.05) (see Supplementary Table S2 for individual SAPS test scores).
Depending on the module, there were significant changes in performance in nine to twelve PWA. For both
phonological modules as well as the lexical- receptive and syntactic-expressive one we rarely determined a decline of
performance (and if, mostly at p<.05 or p<.10). An exception occurred in the syntactic-receptive module, for which
we found an accumulation of significant declines for the easiest level, while there were many significant
improvements for the most difficult level. Out of eleven significant changes on the lowest level of demand in the
16
syntactic- receptive module, in eight PWA there were declines of performance (four times p<.01, two times p<.05
and two times p<.10) and improvements in three PWA (p<.01).
Furthermore, there were similar gains for T-items and C-items (exact Wilcoxon signed-rank test, one-tailed,
p<.01 and p<.05), whereas significant differences between these item pools, especially for the phonological-
receptive and both syntactic modules, turned out to be in favour of improvements for T-items (exact Mann-Whitney-
U Test, one-tailed, p<.10, p<.05 and p<.01).
Influencing factors. Considering influencing factors, we found that compared to participants with non-fluent
aphasia, those with fluent aphasia (n=6) improved significantly more in the phonological- expressive module (exact
Mann-Whitney U Test, one-tailed, p=.001), whereas the baseline performance was not influenced by this factor.
Apraxia of speech did neither influence baseline performance nor performance changes in expressive modules.
Regarding different stages of aphasia, in the phonological- expressive module persons with early chronic aphasia
showed significantly better baseline performance than persons with post-acute aphasia. After Bonferroni-Holm
correction this result did not reach statistical significance. While in general the stages of aphasia did not influence the
change in SAPS-performance or extent and success of learning for the syntactic-expressive module, extent and
success of learning increased continuously across all stages of aphasia (late chronic > early chronic > post-acute;
Jonckheere-Terpstra-test, one-tailed, p=.014).
Differential effects of therapy and home-training
We were able to show a significant therapy effect in most modules (exact Wilcoxon signed-rank test, one-tailed),
especially for medium and high levels of demand. In contrast, some add-on effect of home-training was evident for a
few modules only. The results for set A are illustrated in Figure 8 (Supplementary Figure S2 shows the results for set
B which revealed comparable effects). Comparing effects for therapy versus home-training for set A (respectively, B)
revealed a superiority of therapy (exact Wilcoxon signed-rank test, one-tailed, mostly p<.05 or p<.01). Again, we
17
found significant differences especially for medium and high levels.
- Figure 8 about here -
Construction and feasibility of home-training.
All but one PWA were able to accomplish the home-training, speaking for its feasibility and a good prior estimation
of required instruction comprehension. The exceptional case was excluded from the study during the course of
treatment due to serious problems in understanding and handling of the home-training. He achieved only a percentile
rank of 15 in the Aachen Aphasia Test (AAT; Huber et al. 1983) subtest comprehension, although his comprehension
seemed less impaired in everyday situations. Three PWA had been excluded because of their poor comprehension
skills, corresponding to percentile ranks below 15. All other included PWA showed percentile ranks between 16 and
100, which can be seen in Supplementary Table S3 and S4.
The duration of home-training in the afternoon varied depending on PWA’s computer experience, the
different types of SAPS tasks, the amount of assistance requested by the PWA, as well as comorbidities and
neuropsychological impairments (e.g., apraxia or a reduced attention span). In 14 out of 16 PWA, the frequency of
supervision was sufficient, i.e. PWA became capable to perform the task all by themselves. This might be related to
the consistent structure of the home-training which enabled most of the PWA to easily train independently. In some
PWA, even a lower rate of supervision would have been adequate.
The home-training had been constructed so as to achieve a high number of repetitions at all steps to offer most
intensive stimulation. This procedure was not equally indicated for all PWA. Therefore, the home-training was
somewhat adapted throughout the course of the study to skip particular steps. PWA were asked for feedback to the
home-training and it appears that they were highly pleased with the home-training and enjoyed the possibility to
18
repeat the content of therapy independently on the same day.
Communicative performance (ANELT)
With regard to communicative performance, we found significant improvements for ANELT scales A
(understandability of the message) and B (intelligibility of the message) in three and four PWA, respectively (see
Supplementary Table S5 for individual ANELT test scores), summing up to 5 PWA improving significantly in the
ANELT. Significant deteriorations could only be found for the B-scale, namely in 3 PWA. Interestingly, considering
the whole sample, stable ANELT performance occurred for two PWA with poorest or very low pre-test performance,
respectively (10 and 21 points on scale A; 10 and 24 points on scale B) and for two PWA with best pre-test
performance (43 and 45 points on scale A). Regarding the relation between ANELT and SAPS both before and/or
after treatment (Table 5), there were especially high correlations for A scale performance and the lexical-expressive
and syntactic-expressive modules, with lower ones for the receptive modules of these domains. We also found high
correlations with the phonological modules. By and large, these results were also evident in comparison between the
B scale and SAPS, with the correlations with phonology being particularly strong as well. Finally, effects for both
scales were more pronounced in the post-test compared to the pre-test.
- Table 5 about here –
Discussion
In accordance to the first aim and hypothesis, the treatment regimen was effective for nearly all modules and cells as
featured in the SAPS. There were more significant improvements if a cell was trained, so performance was directly
modulated by training. At the same time, there were similar gains for T-items and C-items on the single case level. In
three modules, fast learning correlated with the extent of change – but overall, there was no substantial difference
19
between the three different types of learning.
We also confirmed supremacy of therapy sessions with regard to hypothesis 2, with some add-on effects of
home-training which demonstrates that it is a useful complement to face-to-face therapy. Whereas we got positive
feedback from PWA, length of training and need for supervision varied within the group. As expected, most of the
PWA coped well with the defined amount of supervision, and home-training was well feasible (hypothesis 3).
Finally, we were able to show significant improvements of everyday communication in the ANELT for some
PWA and positive correlations between communicative and linguistic performance, especially for the lexical-
expressive and syntactic- expressive SAPS-modules, revealing that hypothesis 4 was correct.
Evaluation of treatment design
Regarding the choice of treatment foci, there was large variation within our sample. However, we found that lexical
cells were frequently chosen, while the syntactic- receptive cell was rather neglected (see also Blömer et al., 2013).
Especially at the beginning of the treatment phase, receptive and expressive lexical cells were usually combined.
However, the syntactic module revealed the highest response to training if chosen (improvement in 67% of cases),
followed by phonology (62%), and lexicon being final (38.5%). According to Springer (2008), the relevance of a
lexically oriented therapy arises from the frequent presence of lexical disorders in aphasia. Regarding the sequence of
receptive and expressive cells, in our sample we found the trend to choose receptive prior to expressive demands only
for the phonological modules.
From these finding we can derive valuable recommendations: If a PWA presents with similar levels of
impairments across modules, we suggest starting with the syntactic module before training on the lexical and the
phonological one, in order to not oversee the need for sentence level training to improve functional communication.
Furthermore we suggest training receptive tasks prior to expressive ones, since comprehension is generally less
20
demanding and may ease later access in expressive tasks. If impairments only occur within one module, receptive and
expressive tasks can be combined. The suggested therapy rationale already has been considered in a randomised
controlled trial which applied SAPS as baseline and outcome measure, as basis for one-to-one treatment, and which
also integrated the appended computer-based SAPS home-training into the therapy regimen (Breitenstein et al. 2017).
The amount of trained cells was mainly influenced by two factors: the three different types of learning (fast,
moderate and slow learning) and the severity of symptoms - indicated by not mastered and insecurely mastered cells
in the SAPS baseline. Considering the types of learning, within our sample, there was a large scattering. About half
of the PWA completed all of their cells within two treatment days. Basically, in all modules more PWA finished their
cells after two days of treatment. As mentioned before, fast learning was always completed successfully for both item
sets, whereas in moderate learning at least the first set (A) was successfully terminated (so there is change to the
second set B), and in slow learning the first set was not terminated successfully (so A is trained again); a later
successful termination of set (B) did not influence the procedure (i.e., was not obligatory) (Figure 5). In our sample,
we found a higher percentage of unsuccessfully completed cells for expressive modules. A possible explanation
might be the presence of apraxia of speech within our sample. Even though apraxia of speech was not an influencing
factor on therapy outcomes in general, especially participants who suffered from both aphasia and varying degrees of
apraxia of speech might have profited from more prolonged expressive training, or from a stronger focus on
articulatory processes, which reveals a restriction of our study design. Another explanation for this finding may be the
fact that expressive tasks are generally more demanding than receptive ones; post-hoc analyses of pre-test
performance in SAPS-modules revealed that receptive (mean rank: 17) and expressive (mean rank: 16) modules
altogether did not differ significantly, again indicating the good construction of the SAPS (Mann-Whitney U, one-
tailed, p>.10); however, the syntactic module revealed a significantly better performance in the receptive compared to
expressive modality (p=.042).
Altogether, our findings revealed the soundness of the design, i.e. SAPS-based therapy with a maximum of 4
days per chosen focus is feasible and effective. However, given the variability of PWA responses, the flexible
21
adaption of treatment dose per treatment focus appears to be sensible, since fast learning occurred regularly but not
always.
Changes in SAPS-performance for PWA
Based on group and single case analyses, we found significant improvements in all modules of the SAPS.
Furthermore, we found a positive training effect for therapy and home-training. In nine cells there was a significant
superiority of training compared to no training in group analyses, revealing that the combination of therapy with
home-training and the construction of the home-training were successful. Along the same lines, there were
proportionately more significant improvements for all modules in case of training. These effects were particularly
distinct for the phonological and the syntactic modules. Given that seven out of eight PWA with apraxia of speech
had trained in the lexical-expressive module, apraxia of speech may contribute to the finding that especially the
lexical-expressive module improved less.
Despite the high overall improvement in SAPS modules, we also found an exception within the syntactic-
receptive module. At the lowest level of demand, we found an accumulation of significant declines, while there were
many significant improvements at the highest level within this module. This might be explained by the different
sentence structures and strategies suitable to understand these sentences: At the lowest level of demand, the agent has
to be identified in agent-first sentences. On the moderate and difficult levels of demand, the agent has to be identified
in more complex agent-last sentences. In case that the PWA´s sensitivity and understanding of the variety of
underlying syntactic structures increases, they might abandon their agent-first strategy, leading to a decrease of
performance during post-testing of the lowest level. In case that PWA have already reached a more flexible way of
understanding sentences, they are able to stepwise amplify their syntactic repertoire and improve in their performance
at moderate or highest levels. For SAPS-therapy within the current study, we recommended not to go beyond the
level of demand that was to be treated; while this generally makes sense for clinical practice as well, it might be
worth including the variety of sentence structures for the syntax-receptive module as appropriate for the individual
PWA, including agent-first sentences for the first and agent-last sentences for the second level of demand. Moreover,
22
further picture sets for target and foil sentences could be integrated. All in all, by adding complementary material to
the SAPS-based regimen, the Speech and Language Therapists would become more flexible in using a broad variety
of exercises as necessary to meet the individual needs of the PWA and to retain their good motivation over a longer
period of time by using diverse and individualised material which is important for their everyday life.
While similar gains for T-items and C-items speak for training effects with generalisation to untrained items,
the significant differences between both pools reveal that the effects were specific, i.e. improvements were caused by
study-related training rather than unspecific spontaneous recovery or non-study experience. While for therapy
sessions, the trained material could be flexibly complemented by structurally similar material, the home-training only
focused on the trained items, showing its high drill character.
Regarding the changes in performance within all six modules, there were no differences between the three
recovery stages of aphasia. This confirms great potential for improvement for PWA even in the chronic stage of
aphasia (Rose et al. 2013, Basso and Macis 2011). For the syntactic-expressive module we found an increase in
extent and success of training over the different stages of aphasia (late chronic > early chronic > post-acute). These
results suggest that in the course of recovery from aphasia, those language skills which are important for conducting
those with more complex demands, e.g. the production of complex sentences, become increasingly available and
thereby responsive to treatment.
The three different types of learning (fast, moderate and slow) did not generally influence changes in
performance. Only for the phonological-expressive and both syntactic modules, the changes increased with number
of cells trained and with faster learning. Calculations regarding the influence of apraxia of speech on performance
during baseline or on pre-post changes in the expressive modules revealed no significant differences between
participants with and without this additional disorder.
Overall, the modified version of SAPS revealed to be sensitive to changes in performance caused by
treatment. These results are especially promising since the PWA only trained for the relatively short duration of
23
maximal 16 days. The prolongation of treatment might have further enhanced the outcome, a conclusion which is
supported by the finding that the PWA had not generally reached ceiling as measured by session monitoring.
Effects of therapy and home-training
The analysis of the monitoring of therapy and home-training revealed significant and highly significant effects for
therapy in all modules, especially for medium and high levels of demand. One reason for this is the fact that those
levels were trained more often. Although we also found significant add-on effects by home-training in some SAPS-
cells, therapy generally was superior. However, it remains unclear whether therapy would have been as effective
without home-training, as both were combined throughout.
We conclude that SAPS-based home-training was a useful complement to therapy sessions. It stabilises and
strengthens therapy effects by drill and thereby supports the consolidation of therapy content. In this respect we agree
that computer-based home-training can be integrated effectively into aphasia therapy (Allen et al. 2012, Stachowiak
1993, van de Sandt-Koenderman 2011, Zheng et al. 2016). However, due to the drill character, the procedure is
relatively rigid and inflexible; thus, PWA might already reach ceiling effects after therapy sessions, as measured by
monitoring, which might have prevented further increase of performance during home-training. Even though we
revealed superiority of therapy compared to consecutive home-training as an add-on, the two approaches influence
each other and therefore do not allow for an independent comparison; thus we cannot resolve the question whether
supervised computer-based home-training could replace therapy or not (Aftonomos et al. 1999, Stachowiak 1993).
Nevertheless, we show that therapy frequency can be increased by home-training to reach a sufficient amount of
therapy as required by Bhogal et al. (2003b), Kelly et al. (2011) and Brady et al. (2016).
Construction and feasibility of home-training
Our results show that we included and excluded PWA reliably in line with the fixed criteria. In the course of the
study, only one participant needed to be excluded from participation due to low comprehension performance. Thus,
24
we expect that for PWA with a percentile rank of at least 25 as measured by AATs subtest comprehension, the SAPS-
based home-training is well feasible. This accords with the recommendations for the B.A.Bar home-training from
Nobis-Bosch et al. (2011) for which low language comprehension (at least percentile rank 30 in the AAT subtest
comprehension) also was an exclusion criteria. Although the home-training was constructed to take about 30 minutes
per cell and run, some participants completed the daily home-training sessions faster, and some of them even repeated
the home-training tasks on the same day.
Except for two participants with global aphasia, apraxia and inexperience in computer applications, the
participants coped well with the home-training and were satisfied with the pre-defined amount of supervision. These
findings conform to Nobis-Bosch et al. (2011) and Nobis-Bosch et al. (2006) who determined a comparable amount
of supervision (1-3 hours per week) for the B.A.Bar home-training.
The construction of a computer-based home-training offered the utilization of audio and video files for most
tasks (except for lexical-expressive cells and syntactic-expressive cells levels 1 and 2). Based on clinical observations
and feedback from PWA, an adaption of the home-training appears suitable, including multimodal stimulation (audio,
video) for all tasks and higher flexibility to meet the divergent needs of each PWA (e.g., option to choose the number
of repetitions or levels of stimulation).
Changes in communicative performance (ANELT)
In the ANELT, three and four PWA improved significantly on understandability (scale A) and intelligibility scores
(scale B), respectively. Thus, overall the ANELT results do not show the same level of improvement as the SAPS
results, which is attributed to the challenge in SLT to reach translation to everyday language, over and above
generalisation to other tasks and items. Three PWA deteriorated in intelligibility; however, since phonetic processing
and speech output were no SAPS treatment foci, positive changes in intellibility were not expected to occur. Two
PWA (P33, P19) with very poor (scale A or both) and two PWA (P2, P10) with very good (scale A) pre-test
performance in the ANELT remained stable (Table S5). While these PWA did not improve in the ANELT, post-hoc
25
analysis showed that all of them improved in the SAPS. The ANELT assesses communicative performance and
therefore focusses on successful verbal conveyance of information with the linguistic form being of secondary
interest. In contrast, the SAPS emphasises phonological, lexical and syntactic impairments on different levels of
demand in the receptive and expressive modality. Hence it is possible that PWA reveal high scores in the ANELT
(ceiling-effect) although there are language-systematic impairments, which become evident in the SAPS.
Consequently, the ANELT might not be sensitive to further improvements resulting from language-systematic
treatment. On the other hand, poor performance for individuals with severe aphasia often is not well captured in the
ANELT as well. These PWA might indeed benefit from treatment with a language-systematic focus, but their
improvements were not apparent in the ANELT because the demands in this test are too high (floor effect). For future
research it could be helpful to use the Scenario Test (van der Meulen et al. 2010, van der Meulen et al. 2008) as an
additional diagnostic instrument, as this test allows assessment of communicative skills in individuals with severe
aphasia.
Correlations analyses between SAPS and ANELT revealed the highest positive correlations between
understandability and performance in lexical-expressive and syntactic modules in pre- and post-test. This finding
aligns with Blomert and Buslach (1994) who adduced the importance of specific skills besides general linguistic ones
for reaching a good result in the ANELT. We were able to show improved ANELT-performance after language-
systematic treatment in around one-third of PWA; thus, there is high inter-individual variability in transfer to
everyday communication. For future investigations, it would be desirable to complement our therapy procedure by a
communicative approach as stated by Cicerone et al. (2000). By this, it could be evaluated whether PWA might
further improve their communicative abilities.
Conclusion and relevance
We revealed effectiveness of SAPS based therapy and supervised computer-based home-training as well as their
practicability. Despite the small patient sample size, we found positive effects for impaired language components as
26
measured by the SAPS and in around one-third of PWA also for everyday communication as measured by the
ANELT. Based on the SAPS, an individual performance profile can be assessed and psycholinguistically defined
treatment foci can be derived for therapy and home-training with subsequent evaluation of therapy outcomes. The
current feasibility study builds a firm basis for later controlled trials on aphasia therapy with larger sample sizes.
Acknowledgements
We thank Luise Springer for advice on study design and materials, as well as Katja Halm, Nina Scholtes, Kerstin
Schattka and the SLT team at the Aachen Aphasia Ward for support during conduction of the study.
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