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Top Lang Disord. Author manuscript; available in PMC 2017 April 01.
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Published in final edited form as:

Top Lang Disord. 2016 ; 36(2): 136–153. doi:10.1097/TLD.0000000000000086.

Script Templates: A Practical Approach to Script Training in

Aphasia
Rosalind C. Kaye, PhD. and
Project Manager, Center for Aphasia Research and Treatment, Rehabilitation Institute of Chicago,
Chicago, IL

Leora Reiff Cherney, PhD.

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Director, Center for Aphasia Research and Treatment, Rehabilitation Institute of Chicago,
Chicago, IL. Professor, Physical Medicine and Rehabilitation, Northwestern University Feinberg
School of Medicine, Chicago, IL and Communication Sciences and Disorders, Northwestern
University, Evanston, IL

Abstract
Purpose—Script training for aphasia involves repeated practice of relevant phrases and sentences
that, when mastered, can potentially be used in other communicative situations. Although an
increasingly popular approach, script development can be time-consuming. We provide a detailed
summary of the evidence supporting this approach. We then describe a method in which scripts at
various levels of difficulty are created by systematically manipulating readability and grammatical
and semantic components. We assess the appropriateness of using these template–based scripts
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with persons with aphasia of differing severities.

Method—We evaluated the oral reading performance of eight individuals with chronic non-fluent
aphasia on scripts developed from the templates. Scripts were either of high or low difficulty
relative to their aphasia severity, and personalized by inserting the participant’s town and the name
of an acquaintance. Oral reading probes were taken on three separate days within a week and
performance within and across participants was examined.

Results—Regardless of the participant’s aphasia severity, scripts in the low-difficulty condition

were read with significantly greater accuracy than scripts in the high-difficulty condition.

Discussion—These findings support the use of graded script templates to ensure that
appropriately challenging scripts are delivered to persons with aphasia for both clinical practice
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and research.

Script training in aphasia is a treatment approach that focuses on improving communication

in everyday activities. It typically involves the repeated practice of words, phrases, and
sentences embedded within a monologue or dialogue that is individualized to the person

Corresponding author: Leora Reiff Cherney, PhD, Center for Aphasia Research and Treatment, Rehabilitation Institute of Chicago,
345 East Superior Street, Chicago, IL 60611, Phone. 312-238-1117. Lcherney@[Link].
Disclosure of Funding.
This study was supported by the National Institute on Deafness and Other Communication Disorders, Award No. 1R01DC011754.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on
Deafness and Other Communication Disorders or the National Institutes of Health.
 Kaye and Cherney Page 2

with aphasia. Script practice can be accomplished in various ways, including listening to the
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script, repeating the target utterances, reading them aloud, producing them from memory, or
performing a combination of these activities. Based on the Instance Theory of
Automatization (Logan, 1988), the premise of this approach is that words or phrases within
a script can be successfully mastered with repetitive, cue-based massed drilling. They
become “islands of relatively fluent automatic speech” that are then produced in real-life
discourse (Youmans, Youmans, & Hancock, 2011).

An increasing number of studies have found support for script training in aphasia, using both
objective measures and reports from persons with aphasia, their family, and friends. Table 1
provides a summary of 13 publications that provide evidence for this approach (Bilda, 2011;
Cherney & Halper, 2008; Cherney, Halper, Holland, & Cole, 2008; Cherney, Halper, &
Kaye, 2011; Cherney, Kaye & Van Vuuren, 2014; Cherney, Kaye, Lee, & Van Vuuren, 2015;
Goldberg, Haley, & Jacks, 2012; Lee, Kaye, & Cherney, 2009; Manheim, Halper, &
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Cherney, 2009; Nobis-Bosch, Springer, Radermacher, & Huber, 2011; Van Vuuren &
Cherney, 2014; Youmans, Holland, Munoz, & Bourgeois, 2005; Youmans et al., 2011). It is
important to note that several of the publications present different analyses of data from the
same set of subjects (e.g., Cherney et al., 2014, 2015; Van Vuuren & Cherney, 2014);
however, overall, the studies were conducted by five different research groups and include
over 60 unique participants. Participant characteristics, specifics of the intervention,
outcome measures, and results are compared in Table 1. Successful acquisition of scripts
occurred in all studies. This was true whether or not the scripts were personalized, and
whether practice was principally or exclusively completed with a live therapist, or with
independent practice at home that was supported by technology. Maintenance of the scripts
also was successful to a large extent. Generalized use of specific trained phrases and
sentences in different situations and with different communication partners was generally
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limited. However, participants across several studies reported increased confidence in their
ability to communicate and overall improved communication in everyday situations (Bilda,
2011; Cherney et al., 2011; Youmans et al., 2011).

Essential to any type of script training is the development of a script that is relevant to the
person with aphasia and appropriate for the severity of his or her aphasia. Script
development is best done as a collaborative process together with the person with aphasia
(Holland, Halper, & Cherney, 2010). However, writing an individualized script for each
person is time-consuming, and in the current climate of limited insurance benefits, such an
approach may not even be possible. As an alternative, using a standard script for everyone
may be cost-efficient, and may still impart some of the same benefits as a customized script.
However, if the same script is given to all people with aphasia, and that script is at a single
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level of difficulty, those who are more severe or those who are too mild may not benefit. The
script may be too difficult for those with a severe aphasia and too simple for those with a
mild aphasia.

A similar problem can occur in research studies, where consistency of all but the treatment
variable is essential. If participants with different severities of aphasia are given the same
script, there may be great variability in their pre-treatment level of performance. We
confronted this problem in our own studies. Although participants who were less severe

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received longer scripts, their initial performance accuracy was still considerably higher than
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those who were more severe (64% versus 26.2%), making it difficult to compare absolute
gains across participants (Cherney et al., 2014). In addition, participants who were milder
and started the intervention at a baseline accuracy greater than 80% quickly reached ceiling.

In this report, we describe a method of systematically developing scripts of varying levels of

difficulty for persons with different aphasia severities as determined by the Aphasia Quotient
(AQ) of the Western Aphasia Battery-Revised (WAB-R) (Kertesz, 2006). The method begins
with a simple script template that is systematically modified in terms of readability and
grammatical and semantic difficulty. Personalized content is added to each script so it
becomes more meaningful to the person with aphasia. We also assess oral reading of these
template-based scripts to determine whether or not they are practical to use with participants
who differ in the severity of their aphasia.
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CREATING SCRIPTS
Script Templates
To create the scripts, we chose two topics representing typical situations for most people in
our region: Ordering pizza in a restaurant (with the person with aphasia speaking to a server)
and planning to buy groceries (with the person speaking to a close acquaintance). We next
developed a script template for each topic--a dialogue of 10 turns between the person with
aphasia and the server or acquaintance, with the person with aphasia as the responder in each
turn. The responses of the person with aphasia were written at five different levels of
difficulty by modifying the readability and grammatical and semantic complexity as
described below. The responses of the conversational partner remained the same at all levels.
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Increasing Readability Difficulty

We used the Flesch-Kincaid Grade Level Formula to calculate an overall measure of ease of
readability (Kincaid, Fishburne, Rogers, & Chissom, 1975). This formula uses three
components — syllables, words, and sentences — to create a sentence difficulty measure
(average sentence length, or ASL) and a word difficulty measure (average syllables per word
or ASW) that are then combined to derive a grade level score. The specific formula is
(0.39*ASL) + (11.8*ASW) −15.59. We began with a simple script of 10 turns, with
approximately 5 words per sentence and 1.2 syllables. This corresponded to a Flesch-
Kincaid grade level score of about 0.50 for each of the two scripts. Beginning at this lowest
grade level (level 1), we gradually added more words, sentences, and syllables to each turn.
For example, from level 1 to 2, the restaurant script increased from a total of 62 to 82 words
and 71 to 100 syllables. A spreadsheet was designed so that any change in word, sentence,
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or syllable count automatically recalculated the Flesch-Kincaid score. Table 2 shows how
these measures increased with each grade level, and how the restaurant and grocery scripts at
each level were closely matched.

Increasing Grammatical Difficulty

We used morphemes per word as a measure of grammatical difficulty, based in part on the
reasoning that such a measure would capture inflections on verbs (among other morphemes)

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and that more verbs represent greater clausal complexity. Beginning with the grade 1 scripts,
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which had 62 and 56 words, and 74 and 66 morphemes (1.19 and 1.18 morphemes per
word), we added more multi-morpheme words to each level, so that level 5 had 175 and 172
words, and 230 and 226 morphemes (1.31 morphemes per word).

Increasing Semantic Difficulty

To systematically increase semantic difficulty, the templates contained noun category slots at
various places within the scripts. The words filling each category slot decreased in frequency
of occurrence (and therefore increased in difficulty) at each grade level, while the meaning
of each remained roughly the same. The estimate of a word’s semantic difficulty was derived
from the Corpus of Contemporary American English (Davies, 2008). The less frequent the
word, the more semantically difficult it is. The ten categories, the five words within each
category, and the frequencies of those words are listed in Table 3.
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Below is an example from the pizza restaurant script showing how the words were integrated
into the script at the different levels of difficulty. In this example, the target word is “idea;”
other less frequent words are substituted for idea as the difficulty level increases. Note that
other measures of difficulty such as words and sentences per turn, morphemes per word,
words per sentence, and syllables per word increased along with semantic difficulty.

Semantic category: idea

Server:

All Levels: Then you better get the thin crust.

Person with aphasia:

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Level 1: Good idea.

Level 2: That’s a good thought.

Level 3: That’s good advice. Eating’s not enjoyable when you’re rushing.

Level 4: That’s a very good suggestion. Eating’s not enjoyable when you’re
rushing.

Level 5: That’s a good recommendation. When I’m hungry, I can’t really enjoy
my food.

Personalizing Content
To add a degree of personalization to the scripts, without changing the structural properties
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or grade level, we inserted the names of the participant’s town and a close acquaintance into
each script. Supplemental Digital Content A includes both scripts in their entirety, showing
how each sentence was modified at each level of difficulty.

Matching script level with aphasia severity

As a starting point in matching script difficulty level with aphasia severity, we estimated that
an appropriate or “standard” difficulty level of a script with which to begin training would be

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one where the participant’s independent oral reading accuracy was about 30% on first
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presentation. A script at this difficulty level would be sufficiently challenging for the
participant, and baseline scores of 30% would minimize the potential for a ceiling or
capping of the gains. We selected oral reading as the task on which to measure performance
to minimize errors in production that could occur from problems in auditory working
memory (e.g., in a repetition task).

To evaluate the parameters of such a script in relation to aphasia severity we reviewed a prior
study of script training (Cherney et al., 2014). In this study, eight participants with aphasia,
with WAB-R AQs of 20–80, were given scripts of ten turns but of varying lengths within
each turn depending upon the participant’s severity. Two participants with more severe
aphasia (AQs of 20–40; mean 31.7) and two participants with moderate aphasia (AQs of 50–
60; mean 54.7) had an almost identical mean accuracy of performance on independent oral
reading of the script (25.7% and 26.6% respectively) at baseline. Analysis of the difficulty of
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the scripts showed that syllables, morphemes and words per turn were higher in the scripts
given to the 50–60 AQ group as compared to the 20–40 AQ group (7.3 vs. 6.1 words, 8.7 vs.
7.7 syllables, and 7.9 vs. 6.6 morphemes per turn). We judged that the parameters of these
two script levels were appropriate for the participants with aphasia at these severity levels.
Since no participants had AQs of 40–50, we expanded the upper severity limit of the more
severe aphasia group to an AQ of 50 for purposes of matching script difficulty to aphasia
severity.

In contrast, the pretreatment mean oral reading performance of the four subjects whose
aphasia levels were less severe (AQs of 60–80; mean 72.8) was 64.8% accuracy, with scripts
containing 11.2 words, 13.3 syllables, and 13.2 morphemes per turn. We concluded that the
parameters of these scripts needed to be adjusted to increase script difficulty in order to
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achieve the target 30% pre-treatment accuracy.

DATA COLLECTION AND ANALYSIS

To evaluate the usefulness of this framework, we examined how persons with aphasia would
perform before any treatment was given. We contrasted performance on two different levels
of difficulty, high and low, relative to the person’s severity of aphasia. After determining
parameters for a typical or “standard” level of difficulty based on the prior study as
described above, we defined low difficulty as one level below “standard,” and high difficulty
as one level above “standard.” Assignment of script level based on WAB-R AQ is shown in
Table 4. Note that script level 3 was considered low difficulty for persons with AQs from
60–80 and high difficulty for persons with AQs from 35–50.
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A WAB-R AQ score of 60 was used as a cut-off to divide participants into more and less
severe aphasia groups. Within each severity group, participants were then randomized to
either a low- or high-difficulty script condition.

We used measures of oral reading accuracy to evaluate script performance on the low- and
high-difficulty scripts. We expected that participants who received low-difficulty level
scripts relative to their aphasia severity would perform similarly. We also expected that

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participants who received high-difficulty level scripts relative to their aphasia severity would
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perform similarly, and that their performance would differ from the performance of those
who received low-difficulty scripts.

Oral reading probes of the written script were taken on three separate days within a week. A
version of the AphasiaScripts® treatment software was modified to allow the delivery and
recording of the probes on pre-specified dates via computer. An anthropomorphically
accurate digital “therapist”, who was capable of visually modeling speech, interactively
guided the probes. Delivering the probes via computer removed clinician-related variables
(e.g., clinician expertise, personality factors) that could potentially influence fidelity of
probe administration.

A probe from script level 3 is illustrated in Figure 1. After the digital therapist spoke her
turn, the person with aphasia read aloud his/her part without any cues from the digital
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therapist. The participant then pressed the space bar to go to the next turn, until all ten turns
of the script were read. High-quality recordings of the probes were captured by the computer
program.

Each word of the recorded probes was scored on the Naming and Oral Reading for
Language in Aphasia (NORLA-6) scale (Gingrich et al., 2013), where 0 = no response; 1 =
unintelligible or unrelated response; 2 = semantic or phonological paraphasia; 3 =
appropriate and intelligible responses with minor errors such as the omission of a
grammatical morpheme; 4 = accurate but delayed or self = corrected response; and 5 =
accurate and immediate response. Evidence of the validity and reliability of the NORLA-6
has been previously demonstrated (Cherney et al., 2014, Gingrich et al., 2013).

Each script was scored for percent accuracy derived from the total NORLA-6 accuracy score
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achieved by the participant divided by the maximum possible score for the script (i.e., 5
points per word × the number of words in the script).

RESULTS
Participants
Eight non-fluent individuals with chronic aphasia due to a left-hemisphere stroke
participated. They were native speakers of English, had passed a vision and hearing screen,
and had received no other speech-language therapy services for one month prior to their
participation. Table 5 shows the demographic data for each participant. Their aphasia
severity, based on the WAB-R AQ ranged from 38.0 to 80.8 (M=60.4; SD=16.8).
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The four participants assigned to the relatively high-difficulty scripts were BERJE, DAVAR,
MCCLA, and SCOLI. The fours participants assigned to the relatively low-difficulty scripts
were CLEJO, CORLA, DALRU, and KARYA.

Script Performance
There was no significant difference (p=.48) in mean AQ between participants in the high-
difficulty (mean AQ=55.8; SD=19.3) and low-difficulty (mean AQ=65.1, SD=15.0)

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conditions. Figure 2 shows the oral reading accuracy for each participant at each probe day.
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As expected, the level of difficulty of the script relative to aphasia severity resulted in
consistent oral reading accuracy across participants, except for one outlier (MCCLA).

Visual inspection of each participant’s performance indicates little difference in performance

between probe days 1, 2, and 3. In addition, mean performance by each participant was not
significantly different on the restaurant versus the grocery scripts (p=.60 on a two-tailed
paired t-test). For this reason, the three probe days and two scripts were combined into one
mean probe score for each participant. Mean accuracy per participant is listed in Table 6.
The mean percent accuracy was 26.4% (SD= 21.1%) for the high-difficulty group and
54.3% (SD= 8.8%) for the low-difficulty group. One-tailed t-tests indicated significantly
greater accuracy in oral reading of low-difficulty over high-difficulty scripts (p<.05). The
effect size for low-over high-difficulty scripts was 1.73, which is considered to be large
(Cohen 1988).
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Visual examination of Figure 2 also shows that MCCLA performed differently from the
other participants who were randomized to scripts of high difficulty. Her score of 58% is an
outlier within the high-difficulty condition, as compared to the three other participants’
scores of 16.8%, 14.5% and 16.1%. Using Dixon’s Q-test, MCCLA’s score is characterized
as an outlier at the 99% confidence level for n=4 (Dean & Dixon, 1951; Rorabacher, 1991).
When MCCLA’s scores are omitted, the mean accuracy of the high-difficulty group
decreases to 15.8% (SD=1.2%), and the difference between the high- and low-difficulty
conditions becomes highly significant (p<.0005) in a one-tailed t-test, with a very large
effect size of 6.1 (Cohen, 1988).

Using the restaurant script, we also examined performance on the target words listed in
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Table 3 that decreased in frequency at each grade level. Mean accuracy was 31.5% for words
in the high-difficulty condition and 45.0% for words in the low-difficulty condition. (Note
that the same word could be in the high-difficulty or low-difficulty condition depending on
the participant’s AQ.) A one-tailed t-test indicated no significant difference between the two
conditions (p=0.24). However, once MCCLA, as an outlier, was excluded, a one-tailed t-test
indicated a significant difference between the words in high- and low-difficulty conditions
(p<.05), with a large Cohen’s d effect size of 2.56. Mean accuracy for the high-difficulty
condition then became 15.1%, in contrast to 45.0 % for the low-difficulty condition.

Finally, a minimal amount of personalization seemed to enhance the participants’ sense of

the script’s individualization. While only anecdotal, the majority of participants remarked on
how the insertion of the name of the acquaintance and town made the script feel more
relevant to them.
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DISCUSSION
Script training is an efficacious approach to aphasia treatment, but script development can be
a time-consuming process. We describe a method in which script templates with five levels
of difficulty were created by systematically manipulating readability and semantic and
grammatical difficulty. Eight participants with chronic non-fluent aphasia were presented

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with the scripts at a level that was either of high difficulty (four participants) or low
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difficulty (four participants) relative to their WAB-R AQ. Performance was evaluated by oral
reading accuracy of each script. Regardless of the participant’s aphasia severity, scripts in
the low-difficulty condition were read with significantly (p<.001) greater accuracy (54.4%)
than scripts in the high-difficulty condition (15.8%), with a Cohen’s d effect size for low
over high difficulty of 6.4. These findings support the use of script templates and quantifying
difficulty to ensure consistent performance before treatment.

The main advantage of using script templates over customized scripts is efficiency. Once a
participant’s aphasia severity is known, therapists can choose a previously created script at a
level based on the oral reading accuracy they wish the participant to demonstrate before
beginning treatment. Researchers comparing script learning under different treatment
conditions can also use templates to ensure that participants in all treatment conditions
perform at the same baseline level of accuracy. Treatment fidelity also can be increased by
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using script templates instead of customized scripts. Script creation can be further
streamlined with fewer turns per script, and a minimal level of personalization may be
achieved by simply including names of the participant’s town and close acquaintance.

The purpose of using script templates and varying their difficulty is to achieve a cost-
efficient method of creating scripts that would share the same benefits as time-intensive
customized scripts: (1) being at an appropriate level for the person with aphasia; and (2)
feeling relevant to the person’s everyday life. The first criterion was addressed by
systematically creating five difficulty levels that match the participant’s aphasia severity. The
second criterion was addressed by using templates involving activities common to most
people in the region, and by adding the names of the participant’s town and someone close
to them. There are, however, no studies comparing the effectiveness of treatment with
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customized scripts versus template-based scripts, or whether the additional benefits of

customized scripts—if there are any-- outweigh the cost in therapist time.

There are several limitations to these preliminary findings. Foremost is their generalizability.
Our sample of eight participants with aphasia was small and they were all non-fluent. While
restaurant and grocery scripts at each difficulty level yielded nearly identical performance,
we cannot be certain that this would apply to a wider range of scripts. Future steps to
confirm and refine these findings would involve a larger number of participants and a larger
variety of scripts. Results with fluent participants are also unknown, but they are now being
explored by our research team.

Additionally, script difficulty yielded a consistent pattern of results except for one outlier
(MCCLA) who was randomized to the high-difficulty condition, but performed more like a
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participant in the low difficulty condition. This participant’s oral reading was nearly perfect
(19/20) as measured by the score on the WAB-R Reading Commands subtest, and better
than that of any other participant. The high-difficulty script may have actually been low-
difficulty relative to her abilities. This suggests that the WAB-R oral reading score, rather
than the WAB-R AQ, may be a more accurate determinant of which script level to give to the
participant with aphasia to yield consistent results. More support for this is evident from a
comparison of DALRU and CORLA, who were both assigned level 3 scripts in the low-

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difficulty condition. While CORLA’s AQ (80.8) was higher than DALRU’s (74.5), his
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WAB-R oral reading score (75% of maximum) was lower than DALRU’s (85% of
maximum). CORLA’s probe accuracy (67.1%), like his WAB-R oral reading but unlike his
WAB-R AQ, was also lower than DALRU’s (49%). The evaluation of the WAB oral reading
score and other measures of performance (e.g., auditory comprehension) for matching the
level of script difficulty requires further study.

Another issue is the Flesch-Kincaid score’s sensitivity to minimal text changes when only a
small text sample is analyzed. To demonstrate, we increased the level 2 restaurant script
from grade 1.7 to 2.7 by simply adding the common words about, very, really, dinner, and
probably, and substituting We haven’t ever for We’ve never. A more straightforward and
robust set of measures may be the number of words, syllables, and morphemes per ten turns.
By averaging the counts of the restaurant and grocery scripts, we found that levels 1 through
5 could be closely achieved by starting level 1 with approximately 60 words, 70 syllables,
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and 70 morphemes per ten turns. These counts could then be multiplied by 1.4, 2, 2.5 and
3.25 to approximate levels 2 through 5 respectively. For example, level 2 would be expected
to have 84 words per ten turns (60*1.4), 98 syllables (70*1.4), and 98 morphemes (70*1.4).

The present investigation demonstrates a method of creating scripts from templates that are
systematically altered to produce five levels of measurable difficulty. Performance on oral
reading probes provided evidence to validate these levels of difficulty. Identifying the
appropriate level of difficulty that will promote optimum outcomes that include
generalization to authentic communication situations is a next step in understanding how
best to implement script training. Future steps also would include studying a larger number
of subjects, a greater variety of conversational topics, fluent as well as non-fluent persons
with aphasia, and the effects of modifying various other parameters (e.g., phonetic
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complexity of the words) that may contribute to difficulty levels. In addition, comparing
treatment outcomes using customized versus template-based scripts could yield valuable
information about the costs and benefits of script training,

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The authors extend their thanks to Sarel van Vuuren, Co-PI on the grant supporting this study; to Rachel Hitch and
Rosalind Hurwitz who collected and/or scored the data; and to Nattawut Ngampatipatpong, who modified the
AphasiaScripts® software for the purposes of this study.
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Van Vuuren, S.; Cherney, LR. A Virtual Therapist for Speech and Language Therapy. In: Bickmore, T.;
Marsella, S.; Sidner, C., editors. Intelligent Virtual Agents 14th International Conference, IVA
2014, Lecture Notes in Artificial Intelligence. Vol. 8637. Springer International Publishing;
Switzerland: 2014. p. 438-448.
Youmans G, Holland A, Munoz M, Bourgeois M. Script training and automaticity in two individuals
Author Manuscript

with aphasia. Aphasiology. 2005; 19:435–450.

Youmans G, Youmans S, Hancock A. Script training treatment for adults with apraxia of speech.
American Journal of Speech-Language Pathology. 2011; 20:23–37. [PubMed: 20739633]

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 Kaye and Cherney Page 11
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Figure 1.
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Screenshot of a probe. The digital therapist speaks her turn, then the participant reads the
response aloud without cues.
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 Kaye and Cherney Page 12
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Figure 2.
Accuracy of probes 1, 2, and 3 for each subject in the high-difficulty (n=4) and low-
difficulty (n=4) script conditions.
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Author Manuscript

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Table 1

Summary of aphasia script studies (in chronological order)

Kaye and Cherney

Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &
chronicity
Script training and 2 Broca’s, AQ Single 3 scripts per Per script: Sessions in clinic with therapist Probes of script production without 3 scripts
automaticity in 48.7 subject, participant using repetition and memorization. support mastered in 25–
two individuals Conduction, multiple Scripts were 3–4 • Clinic: Practice at home with support of Percent script correct 26 sessions by
with aphasia. AQ 68.8 baseline sentences and 30–45 audiotapes from client-clinician Rate of script-related words each person
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

Youmans et al. At least 10 13–32 words min/ practice. Errors with aphasia.
(2005). years post- Personalized: session 3 Practiced scripts as monologues, (Mastery =
stroke Participant and sessions/ then in conversational contexts with scripts
clinician wk therapist. produced from
collaborated on memory with
• Home:
topics and 97–100%
15
wording. accuracy)
min/day
Increased
1 script begun after mastery of speaking rate
previous script. Relatively
errorless
production.
Generalized to
conversations,
novel partners
and cues only in
a limited
fashion.

Computerized 3 Broca’s, Single 1 monologue & Per script Person with aphasia practiced with Probes of oral reading of scripts: All participants
script training for Wernicke’s, subject, 2 dialogues per virtual therapist on computer, cued Content (# and % of script-related showed positive
aphasia: Anomic multiple person w • Clinic 1 by written words, choral speaking, words) changes in the
Preliminary WAB AQ baseline aphasia. 30-min and oral-motor movements of the Grammatical productivity (# of content,
results. Cherney et range 50.4– across scripts Scripts were 8– visit/wk virtual therapist. Cues gradually morphemes, nouns, verbs, grammatical
al., (2008). 73.2 10 turns, with removed each week. modifiers) productivity,
• Home 30
At least 6 40–140 words Rate of script-related words and rate of
min/day
months post- per script. WAB AQ, CADL-2, QCL scale script
minimum
stroke Personalized: production.
6
Person w 2 of 3
days/wk
aphasia and participants
for 3 wks
clinician showed
collaborated on Scripts practiced consecutively clinically
topics and significant
wording. improvements
on the WAB
AQ
No
improvement
on CADL-2 or
QCL

Page 13
Novel technology 3 2 Nonfluent Single 1 monologue & Per script Person with aphasia practiced with Probes of oral reading of scripts: Variability
for treating 1 Fluent subject, 2 dialogues per virtual therapist on computer, cued across scripts; 2
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
indiviudals with WAB AQ = multiple person w • Clinic 1 by written words, choral speaking, Content (# and % of script-related participants
aphasia and 51.4 and baseline aphasia. 30-min and oral-motor movements of the words) improved on 2
concommitant 51.9 for across scripts Scripts were 8– visit/wk virtual therapist. Cues gradually Grammatical productivity (# of of 3 scripts in
cognitive deficits. Nonfluent; 10 turns, with removed each week. morphemes, nouns, verbs, measures of
Cherney & Halper 81 for Fluent 40–140 words • Home 30 modifiers) content,
(2008). At least 6 per script. min/day Rate of script-related words grammatical
months post- Personalized: minimum WAB AQ, CADL-2, QCL scale productivity,
stroke Person w 6 and rate of
aphasia and days/wk script
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

clinician for 3 wks production.

collaborated on 1 of 3
Scripts practiced consecutively
topics and participants
wording. showed
clinically
significant
improvements
on the WAB
AQ
Patient-reported 20 14 Non- Single 1 monologue & Per script Person with aphasia practiced with Communication Difficulty (CD) There was a
changes in fluent, 6 subject, 2 dialogues per virtual therapist on computer, cued subscale of the Burden of Stroke statistically
communication Fluent multiple person w • Clinic 1 by written words, choral speaking, Scale (BOSS) significant
after computer- WAB AQ baseline aphasia 30-min and oral-motor movements of the decrease in the
based script 30.5–85.3 across scripts Scripts were 8– visit/wk virtual therapist. Cues gradually CD subscale of
training for Mean 64.57, 10 turns, with removed each week. the BOSS.
• Home 30
aphasia. Manheim SD 15 40–140 words Maintained 6
min/day
et al., (2009) At least 6 per script. wks later
minimum
months post- Personalized:
6
stroke Person w
days/wk
aphasia and
for 3 wks
clinician
collaborated on Scripts practiced consecutively
topics and
wording.

Conversational 17* Non-fluent Single 1 monologue & Per script Person with aphasia practiced with Probes of oral reading of scripts: Amount of
script performance WAB AQ subject, 2 dialogues per virtual therapist on computer, cued Content (# and % of script-related practice hours
in adults with non- 30.5–85.3 multiple person w • Clinic 1 by written words, choral speaking, words) significantly
fluent aphasia: Mean 65.1, baseline aphasia 30-min and oral-motor movements of the Rate of script-related words correlated with
Treatment SD 15.3 across scripts Scripts were 8– visit/wk virtual therapist. Cues gradually gain in the % of
intensity and At least 6 10 turns, with removed each week. script-related
• Home 30
aphasia severity. month post- 40–140 words words in more
min/day
Lee et al., (2009) stroke per script. severe aphasia,
minimum
Personalized: and with rate of
6
Person w script-related
days/wk
aphasia and words in less
for 3 wks
clinician severe aphasia
collaborated on Scripts practiced consecutively
topics and
wording.

Page 14
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
Computer-based 23** 15 Single 1 monologue & Per script Person w aphasia practiced with Post-treatment interviews of 584 coded
script training for Nonfluent, 8 subject, 2 dialogues per virtual therapist on computer, cued persons with aphasia and/or comments were
aphasia: Emerging Fluent multiple person w • Clinic 1 by written words, choral speaking, significant other person were categorized into
themes from post- WAB AQ baseline aphasia 30-min and oral-motor movements of the recorded, transcribed, and 10 themes,
treatment 30.5–90 across scripts Scripts were 8– visit/wk virtual therapist. Cues gradually categorized. including
interviews. At least 6 10 turns, with removed each week. improved
• Home 30
Cherney et al. months post- 40–140 words verbal and
min/day
(2011). stroke per script. written
minimum
Personalized: communication,
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

6
Person w increased
days/wk
aphasia and confidence,
for 3 wks
clinician participation in
collaborated on Scripts practiced consecutively ADL and
topics and community
wording. activities, and
changes noticed
by others.
Other themes
included
satisfaction
with the overall
study,
personalization
of scripts, and
use of
computer.

Video-based 5 Broca’s, Case-series 20 scripts Scripts presented consecutively Person with aphasia heard and saw Target sentence in each script Statistically
conversational Wernicke’s, trained; 28 for 3 hours/day for 10 days videos of actors speaking scripts in scored w the 0–3 scoring scale of significant
script training for Anomic untrained; 2 All training in clinic real-life scenes. Cues increasingly the Naming subtest of the AAT improvement in
aphasia: A therapy At least 1 served as removed until participant mastered a AAT, CAL, CETI, ANELT, SAQOL target phrase
study. Bilda year post- practice conversation with the video partner. production
(2011). stroke examples Different scripts were practiced Improvement
Large range Scripts were 3 consecutively during a session. maintained at 4
of severity turns with 3–7 Clinician managed program and wks and 6 mo
as measured words per turn. motivated participant. post.
by AAT Nonpersonalized Less, but still
subtests significant,
improvement in
untrained
scripts.
Improvements
on the naming
and repetition
subtests of the
AAT.
increased
confidence and
improvement in
communication

Page 15
skills in
everyday
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
situations for 2
participants on
the CETI and
ANELT..

Supervised home 18 Broca’s, Crossover 48 scripts The crossover conditions were In each 3-turn script, 2 dialogue Therapist posed questions which Significant
training of Transcortical Scripts were 3 script vs. nonlinguistic cognitive partners were depicted by icons with had to be answered by person w improvements
dialogue skills in or Global turns of 3–5 training. Randomly ordered speech bubbles containing bar codes. aphasia without support. in linguistic and
chronic aphasia: A At least 6 words per turn. presentation of conditions. After person w aphasia scanned the Dialogue rated on separate scales of communicative
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

randomized months post- Non- barcode, the pictured person spoke 1–4 for communicative success and abilities using
parallel group stroke personalized • Clinic: 1 his /her lines. Persons w aphasia linguistic accuracy. B.A. Bar
study. Nobis- AAT: hr/wk 4 then read their response and repeated Word fluency training but not
Bosch et al., Naming wks it. Pattern recognition and visual with
(2011). subtest Each script had to be practiced first scanning nonlinguistic
• Home: 1
below 50 with writing, then without. Auditory & visual memory span training.
hr/
percentile; Wks 1 & 3: 24 food & shopping Spontaneous speech analyzed re The transfer to
session, 2
Repetition scripts; Wks 2 & 4 : 24 health- basic linguistic parameters general
sessions/
and Speech related scripts. Related vocabulary ANELT, AAT, CETI linguistic and
day, 4
subtests drills with all scripts. communicative
days/wk
above 30 Nonlinguistic cognitive training had performance
4 wks
percentile. same intensity duration as script remained
4 wk washout between training. limited.
conditions

Script training 3 AOS and Single 3 scripts Per script: • Clinic: At Probes of spontaneous production All successfully
treatment for mild subject, Scripts were 3–7 least 3 10- while speaking on each script topic: acquired their
adults with apraxia Anomic multiple turns, with 12– • Clinic: min episodes scripts, and
of speech. aphasia baseline 51 words per 2–3 of • % of script demonstrated
Youmans et al., WAB AQ script. hrs/wk concentrated words script retention
(2011). 50.3–75.6 Personalized: with script produced 6 months later.
At least 1 Person w clinician training correctly Errors remained
year post- aphasia and practice, variable as did
• Home: • Rate of
stroke clinician interspersed speaking rate.
15 min/ script-
collaborated on w brief Time for a
session, 2 related
topics and periods of person w
sessions/ words
wording. relaxed, aphasia to
day, 7
open Errors master all 3
days/wk
conversation. Self-report ratings on confidence scripts ranged
Scripts practiced consecutively; 1 Beginning of and production for each script topic from 22–44
script begun after mastery of each session, sessions.
previous script. persons w All reported
aphasia were increased
audio- confidence and
recorded speaking ease.
while
speaking on
each of their
3 topics.
• Home:

Page 16
Persons w
aphasia
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
practiced at
home via a
tape recorder
and written
cue cards.

Script training and 2 Broca’s, Single 2 scripts Per script: Sessions with therapist in person Probes of oral reading of scripts: Improvement
generalization for post-TBI, subject, Scripts were 4–9 combined with videoconferencing. on all measures
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

people with WAB AQ multiple turns, with 28– • Clinic. 3 Cuing gradually removed • % correct of during and after
aphasia. Goldberg 57.2 baseline 88 words per sessions/ script- treatment
et al., (2012). 6 yrs post- script wk for 3 related phase.
onset Personalized: wks. 4 words Generalization
Conduction Person w and 4.5 samples showed
hrs per • %w
WAB AQ aphasia and improved
script grammatical
87.5 clinician grammatical
total morphemes
5 yrs post- collaborated on morpheme use
onset topics and Disfluencies per word and increased
• Home.
wording. Rate of script-related words rate of speech
15
min/day Generalization: Person w aphasia
using tried to converse about script topic
clinician with partners who didn’t follow the
recording script.
of script
as
support
Scripts practiced consecutively

Acquisition and 8 7 Nonfluent, Crossover 1 trained script, The crossover conditions were Person w aphasia practiced with Probes of oral reading of scripts: Significant
maintenance of 1 Fluent 2 untrained script training in a high vs. low virtual therapist on computer. In improvement in
scripts in aphasia: WAB AQ scripts cue condition. Randomly ordered high-cue condition, persons w • % accuracy both accuracy
A comparison of 28.1–80.1 Scripts were 10 presentation of conditions aphasia were cued by written words, and rate from
• Rate of
two cuing At least 6 turns, with 50– Per script: choral speaking, and oral-motor baseline to
script-
conditions. months post- 125 words per movements of the virtual therapist. post-tx and
• Clinic: related
Cherney et al., stroke script In low-cue condition, persons w maintenance in
30 words
(2014). Clinician aphasia practiced sentences with both conditions.
determined topic min/wk written cues only, followed by No statistically
and wording, hearing and seeing each sentence significant
• Home:
adding 4 read by the virtual therapist. difference
30 min/
personalized between high
session;
items to each vs. low cue,
3
script although
sessions/
consistently
day 6
better
days/wk
performance in
for 3 wks
acquisition
3 wks washout between phase under
conditions. high cue
condition.

Page 17
Difference in
magnitude of
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
change between
conditions
greater for
those with more
severe aphasia.
Subjects
expressed
preference for
high cue
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condition.
Performance
generally
maintained for
3 and 6 weeks
post treatment.

A virtual therapist 8 7 Nonfluent, Crossover 1 trained script, The crossover conditions were Person w aphasia practiced with Probes of oral reading of scripts: High-cue
for speech and 1 Fluent 2 untrained script training in a high vs. low virtual therapist on computer. In condition led to
language therapy. WAB AQ scripts cue condition. Randomly ordered high-cue condition, persons w • % accuracy faster learning
Van Vuuren & 28.1–80.1 Scripts were 10 presentation of conditions aphasia were cued by written words, and higher
• Rate of
Cherney (2014) At least 6 turns, with 50– Per script: choral speaking, and oral-motor gains.
script-
months post- 125 words per movements of the virtual therapist.
• Clinic: related
stroke script In low-cue condition, Persons w
30 words
Clinician aphasia practiced sentences with
determined topic min/wk written cues only, followed by Mixed effects model used to
and wording, hearing and seeing each sentence analyze gains over time.
• Home:
adding 4 read by the virtual therapist.
30 min/
personalized
session;
items to each
3
script
sessions/
day 6
days/wk
for 3 wks
3 wks washout between
conditions.

Impact of personal 8 7 Nonfluent, Crossover 1 trained script, The crossover conditions were Person w aphasia practiced with Probes of oral reading accuracy of Significant
relevance on 1 Fluent 2 untrained script training in a high vs. low virtual therapist on computer. personalized and non-personalized improvement in
acquisition and WAB AQ scripts cue condition. Randomly ordered Persons w aphasia were cued by words/phrases that were shared by accuracy for
generalization of 28.1–80.1 Scripts were 10 presentation of conditionsPer written words, choral speaking, and trained and generalization scripts both
script training for At least 6 turns, with 50– script: oral-motor movements of the virtual personalized
aphasia: A months post- 125 words per therapist. and non-
preliminary stroke script • Clinic: personalized
analysis. Cherney Clinician 30 words/phrases
et al., (2015) determined topic min/wk in both trained
and wording, and
• Home:
adding 4 generalization
30 min/
personalized script.
session;
items to each The gain of
3

Page 18
script personalized
sessions/
items was
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Title, author, year N Aphasia Study design Script design Treatment schedule Treatment administration Outcome measures Main outcomes
type,
severity &

Kaye and Cherney

chronicity
day 6 greater than
days/wk non-
for 3 wks personalized
items in the
3 wks washout between trained but not
conditions. untrained script.

*
Included the participants with nonfluent aphasia in Cherney (2008), Cherney & Halper (2008), and Manheim (2009)
Top Lang Disord. Author manuscript; available in PMC 2017 April 01.

**
Included the 3 participants from Cherney (2008), and 20 participants from Manheim (2009),

AAT=Aachen Aphasia Test; ANELT=Amsterdam-Nijmegen Everyday Language Test; AOS=Apraxia of speech; AQ=Aphasia Quotient; BOSS=Burden of Stroke Scale; CADL-2=Communication Activities
of Daily Living; CAL=Communicative Activity Log; CETI=Communicative Effectiveness Index; QCL=Quality of Communication Life Scale; SAQOL=Stroke and Aphasia Quality of Life Scale;
WAB=Western Aphasia Battery

Page 19
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Table 2

Counts per ten turns in the restaurant and grocery script at five levels of difficulty

Restaurant Script Level 1 Level 2 Level 3 Level 4 Level 5

Sentences 11 11 15 15 19
Words 62 82 114 141 175
Kaye and Cherney

Syllables 71 100 145 188 245

Morphemes 74 98 145 181 230
Words/sentence 5.6 7.5 7.6 9.4 9.2
Syllables/word 1.1 1.2 1.1 1.3 1.4
Morph/word 1.19 1.20 1.27 1.28 1.31
Flesch-Kincaid 0.12 1.71 2.38 3.81 4.52

Grocery script Level 1 Level 2 Level 3 Level 4 Level 5

Sentences 11 13 14 14 16
Words 56 78 108 142 172
Syllables 69 98 144 186 241
Morphemes 66 95 133 179 226
Words/sentence 5.1 6.0 7.7 10.1 10.8
Syllables/word 1.2 1.2 1.3 1.2 1.41
Morph/word 1.18 1.22 1.23 1.26 1.31
Flesch-Kincaid 0.93 1.58 3.15 3.82 5.14

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Table 3

Frequency of Occurrence in Contemporary English of the Words Within Each Category Slot of the Restaurant Template

Difficulty level Type of salad Pizza topping 1 Pizza topping 2 Time Idea
1 house 213,652 peppers 24,082 cheese 20,331 six 98,285 idea 133,328
2 garden 42,083 mushrooms 7,213 sauce 18,089 seven 56,577 thought 55,123
Kaye and Cherney

3 greens 25,470 sausage 4,106 onions 15,995 one 49,840 advice 24,189
4 chef 12,432 spinach 3,231 garlic 13,102 forty-five 1,834 suggestion 14,191
5 antipasto 113 pepperoni 338 basil 4,708 six-thirty 186 recommendation 12,816
Difficulty level Salad ingredient Portion of food Show Dessert Time of day
1 tomato 16,639 size 55,904 show 96,566 cake 14,858 now 657,619
2 cucumber 8,447 amount 53,868 movie 74,861 pie 10,130 today 199,257
3 carrots 6,378 portion 16,904 play 45,361 brownies 1,422 tonight 52,781
4 radishes 850 serving 11,003 concert 14,683 cheesecake 976 afternoon 35,771
5 salami 455 helping 2,435 musical 2,321 cobbler 566 evening 4,432
Difficulty level Mean frequency of all ten words
1 115,531
2 44,191
3 24,082
4 9,883
5 3,235

Note. Frequency of occurrence in a corpus of 450 million spoken and written words in contemporary American English, from The Corpus of Contemporary American English (Davis 2008 -).

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Table 4

Script Levels for Standard, Low, and High Difficulty: Assigned to participants based on their WAB-R AQ
Author Manuscript

Script level assigned

WAB-R AQ range Standard difficulty Low difficulty High difficulty

35 – 50 2 1 3
50 – 60 3 2 4
60 – 80 4 3 5

Note. The WAB-R AQ is the Aphasia Quotient on the Western Aphasia Battery-Revised, (Kertesz, 2006).
Author Manuscript
Author Manuscript
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Table 5

Participant Characteristics

Subject Age (yrs) Gender Race Handedness TPO (mos) Education (yrs) WAB-R AQ WAB-R % Oral Reading Randomized Script Difficulty
BERJE 47.09 M B L 8.92 12 41.7 20 High
CLEJO 76.38 M W R 42.48 16 49.4 10 LOW
Kaye and Cherney

CORLA 67.33 M W R 151.54 18 80.8 75 LOW

DALRU 52.59 M W R 29.64 16 74.5 85 LOW
DAVAR 39.59 F B R 54.89 17 64.6 25 High
KARYA 61.11 M B R 33.74 19 55.5 45 LOW
MCCLA 39.19 F W R 15.67 14 78.7 95 High
SCOLI 72.47 F B L 100.32 18 38.0 20 High

Mean 57.0 54.7 16.3 60.4 46.88

SD 14.5 48.2 2.3 16.8 33.48

Note: The eight non-fluent participants had chronic aphasia due to a left hemisphere stroke. All subjects except MCCLA and KARYA had some associated apraxia of speech.

M=male; F=female; B=black; W=white; L=left; R=right

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Table 6

Mean % Accuracy of Oral Reading Probes, With the Restaurant and Grocery Scripts Combined

High-difficulty condition Low-difficulty condition

PWA Script level % accuracy PWA Script level % accuracy

DAVAR 5 16.8 CORLA 3 49.0
Kaye and Cherney

BERJE 3 14.5 KARYA 2 53.4

MCCLA 5 58.0 DALRU 3 67.1
SCOLI 3 16.1 CLEJO 1 47.9

mean 26.4 mean 54.3

SD 21.1 SD 8.8
Without MCCLA: mean 15.8
SD 1.2

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