A hallmark of aphasia, or language problems after a stroke or brain injury, is difficulty finding words. This word-finding problem, also known as anomia, can be extremely frustrating and long-lasting. Traditional treatments for naming problems often involve looking at a picture and trying to say the name of it, sometimes with cues or hints to help the person think of the word.
But what about words that can’t be represented by pictures, or, once you’ve mastered all the basic words and are still having trouble? That’s when you need to try VNeST.
The Treatment: VNeST
What is VNeST? It stands for Verb Network Strengthening Treatment, and it’s a relatively new therapy procedure developed primarily by Dr. Lisa Edmonds, PhD, CCC-SLP. The VNeST method focuses on verbs, encouraging participants to think of the people who perform the actions (known as agents) and the objects or people the actions are performed on (known as patients).
The idea is that by focusing on verbs, which require connections to nouns, you can strengthen all the words in the mental network around the verb. This will target a variety of words and help you think of the words faster and more independently. It’s by design that the therapy does not use picture cards – it is meant to activate the mental images and words in the brain and encourage flexible thought.
The best part about the research into VNeST is that it shows the gains made in therapy generalize, or show up on words that were never practiced. This isn’t a result we typically see in other types of word-finding therapy. It’s also been effective for people with aphasia ranging from moderate-severe to mild, as long as they’re able to understand the instructions and have some ability to speak or write the answers.
Choosing Verbs for VNeST
All you really need to start doing VNeST is a list of verbs. Here are a few guidelines for selecting appropriate verbs for this type of therapy:
First, they need to be transitive verbs, in that they take an object. This means catch will work (“the dog catches the ball”), but arrive won’t (“the woman arrives”).
Next, the verbs should be familiar, but not too generic. Our most common verbs, like do, is, and have, can take almost any word after them, so it’s harder to think of specific people and things associated with those verbs. In comparison, teach is a nice everyday verb that’s specific enough to define who can do it (teachers, parents, professors) and what can be taught (lessons, courses, students).
In a research study on VNeST, the same 10 verbs are practiced 3.5 hours a week for 10 weeks. Participants attempted to complete all 10 verbs each week.
Finally, the verbs should be different from each other. Since we’ll be targeting networks in the brain, we don’t want too much overlap. For example, while slice, chop, and cut would each be suitable, they shouldn’t be used together.
How To Do VNeST
Now that you’ve got a list of verbs, write each one on a 3×5 notecard. Make cards that say “WHO” and “WHAT” to put on either side of the verb card. You’ll take one verb through all 6 steps, then move to the next verb.
Step 1: Create 3 pairs of subjects/objects for the verb. Think of 3 people who could perform the action, or start by thinking of 3 objects the action could be done to. It might be easier to work on one complete set at a time, thinking of the agent and patient together. The goal is to be as specific as possible with the nouns, so farmer would be a better agent than man for the verb drive. Write each noun on a card and place it in the appropriate column so you’ll have 3 triads (subject-verb-object).
It’s okay to get personal. Family members, friends, and pets make great agents for VNeST! Just try to vary the responses, so not all the nouns are personal or one type of profession. Similarly, try to use many different meanings of the verb if possible.
If the client needs help, it’s good to prompt with questions about who might do this for their job, their hobby, or in a certain location. This would be considered a minimal cue. If that’s not enough, you can provide a maximal cue by giving choices. The client can write their responses themselves, or you can do it for them.
Step 2: Read each triad of words aloud. It’s not important to conjugate the verb or add any articles to the nouns (“farmer drive tractor”), but it’s okay if the client does (“the farmer drives the tractor”). Take note of whether the client reads independently, needs to read in unison with you, or repeats each word after you, as a way to measure progress on this step.
Step 3: Select one of the three triads to expand upon. Ask “WHERE” it happens, “WHY” it happens, and “WHEN” it happens as you show cards with those words. Try to get specific answers, and write the responses down. Then have the client read the original triad followed by the three answers to create a long, detailed sentence. Again, the grammar doesn’t matter as the focus is on connecting the concepts.
Step 4: Clear the cards from the table, and read aloud 12 sentences that use the verb (best prepared in advance). These should contain a mix of correct and incorrect sentences. Some will have a wrong agent, others a wrong patient, and some will have the themes reversed. Ask the client to judge whether each sentence they hear is correct or not.
Step 5: Recall the verb you’ve been working on. If the client can’t independently remember the verb, cue them to think of the three subject/object pairs. If that doesn’t help, show them the card with the printed verb.
Step 6: Repeat step 1, but this time without cues. This does not mean that the client has to remember the same 3 pairs of nouns, but they can, or it’s okay to come up with new pairs.
It is not necessary to follow the procedure step-by-step every single time. Rather, it’s important to understand the theory behind the steps and adjust as needed. Remember too, that this is an activation treatment, not a memorization treatment, so the responses can change each time.
VNeST using the Advanced Naming Therapy App
While the VNeST protocol is relatively straightforward and easy to do with just pen and paper, it can be challenging to remember all the steps or train families to do it at home. This is where technology becomes very useful!
The Create activity in the Advanced Naming Therapy app is an adaptation of the VNeST protocol. This activity takes users through the process of generating noun pairs, reading the triads aloud, expanding a selected set by answering 3 wh- questions, recalling the verb, and composing the sentences again; it omits only the sentence judgments in step 4.
Try Advanced Naming Therapy for FREE by downloading Advanced Naming Therapy Lite. Practice 3 verbs in the Create activity to see how VNeST can work.
For the clinician, the app provides 25 sets of 10 verbs, balanced for frequency and meaning, and offers optional on-screen scoring to record the level of assistance. For the home user, built-in choices, hints, predictive text, and voice dictation encourage independence and enable intensive practice. Detailed reports that can be emailed from the app to the clinician make tracking progress easy. Family members, volunteers, and students can be trained how to provide helpful cues and supportive feedback to keep therapy personalized and positive.
Advanced Naming Therapy provides 4 activities to work on higher-level word finding skills. Read more about this exciting new app.
Resources for VNeST
There are several helpful online resources to learn more about VNeST. Dr. Lisa Edmonds, PhD, CCC-SLP is actively researching, publishing on, and further refining the treatment. Much of this how-to guide is based on her helpful tutorial published in the ASHA SIG 2 Perspectives: Edmonds, L. A. (2014). Tutorial for Verb Network Strengthening Treatment (VNeST): Detailed description of the treatment protocol with corresponding theoretical rationale. SIG 2 Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 24(3), 78-88.
If you’re a member of SpeechPathology.com to earn CEUs, look up Dr. Edmonds’ video course explaining VNeST from 2013. Or if you prefer, this 1hr40min video of Dr. Edmonds lecturing at MossRehab from 2009 is freely available on YouTube.
A recent review of the evidence is published here: Edmonds, L. A. (2016). A review of Verb Network Strengthening Treatment: Theory, methods, results, and clinical implications. Topics in Language Disorders, 36(2), 123-135. (full text PDF)
Finally, a study showing positive results using a computerized version of VNeST through tele-therapy can be found here: Furnas, D. W., & Edmonds, L. A. (2014). The effect of computerized Verb Network Strengthening Treatment on lexical retrieval in aphasia. Aphasiology, 28(4), 401-420. (related full text)
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