Brain Injury, June 2006, 20(6): 559–568

REVIEW

Identification of aphasia post stroke: A review of screening

assessment tools

KATHERINE SALTER1, JEFFREY JUTAI1,2, NORINE FOLEY1, CHELSEA HELLINGS1, &

ROBERT TEASELL1,2
1
Department of Physical Medicine and Rehabilitation, Parkwood Hospital, St. Joseph’s Health Centre, London,
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Ontario, Canada and 2Schulich School of Medicine and Dentistry, University of Western Ontario, London,
Ontario, Canada

(Received 13 October 2005; accepted 8 April 2006)

Abstract
Introduction: Aphasia is one of the most common consequences of stroke. Early identification, diagnosis and treatment of
For personal use only.

language deficits are important steps in maximizing rehabilitation gains. A routine screening test is an invaluable tool in the
identification and appropriate referral of patients with potential communication problems. The present study presents an
evaluation of the measurement properties of screening tools for aphasia found within the stroke research literature.
Methods: Screening tools were identified following searches of the published research literature in stroke. Instruments were
reviewed on the basis of reliability, validity, classification sensitivity and practical utility.
Results: Six aphasia screening tools were identified. For most tools, information pertaining to measurement properties and
clinical utility was limited.
Conclusions: The Frenchay Aphasia Screening Test (FAST) appears to be the most widely used and thoroughly evaluated
tool found within the stroke research literature. Further evaluation of the measurement properties and clinical utility of
screening tools is recommended.

Keywords: Aphasia, screening, assessment, stroke

Introduction It has been demonstrated that aphasia therapy,

It has been reported that aphasia is one of the most
common consequences of stroke in both the acute
and chronic phases. Acutely, it is estimated that from
21–38% of patients with stroke are aphasic [1].
During the first year following the stroke event,
aphasia tends to improve. A review by Ferro et al. [2]
reported that
40% of acutely aphasic patients
experience complete or almost complete recovery
by 1 year post stroke. While 61% of aphasic patients
in the Copenhagen Aphasia Study still experienced
aphasia at 1 year post-stroke, it was usually of a
milder form [3].
if delivered with sufficient intensity over a period
of 2–3 months, is effective in improving language
outcomes for individuals who are aphasic following
stroke [4]. Early involvement in appropriate, inten-
sive therapy not only coincides with patterns of
neural recovery [5], but also serves to increase the
opportunity for the development of coping strategies
for communication, thereby reducing patient
isolation and promoting participation in the rehabil-
itation process [6, 7]. Therefore, early identification
and diagnosis of language deficits is an important
step toward maximizing rehabilitation gains.
However, given constraints in both funding

Correspondence: Katherine Salter, BA, Department of Physical Medicine and Rehabilitation, St. Joseph’ Health Centre – Parkwood Hospital,
801 Commissioner’s Rd. E, London, Ontario N6C 5J1, Canada. Tel: 519 685 4559. Fax: 519 685 4023. E-mail: katherine.salter@sjhc.london.on.ca
ISSN 0269–9052 print/ISSN 1362–301X online ß 2006 Taylor & Francis
DOI: 10.1080/02699050600744087
 560 K. Salter et al.

Table I. Evaluation criteria for the selection of outcome measures.

Criterion Definition

Appropriateness The suitability of the measure to the purpose or question under study. The appropriateness of the tool
will depend on the specific purpose for which the tool was developed as well as the circumstances of
the assessor(s).
Reliability Reproducibility (the degree to which the result is free from random error) and internal consistency
(the homogeneity of the scale items) of the scale.
Validity Does the instrument measure the intended construct? Forms of validity include face, content, construct
and criterion (concurrent, convergent, discriminative, predictive). Note that criterion validity
depends upon comparison to an accepted gold standard. If no gold standard exists, these represent
a form of construct validity in which the relationship to another measure or indicator is
hypothesized [46].
Responsiveness The ability of the measure to reflect change in the construct being measured over time. Assessment of
possible floor and ceiling effects are included in responsiveness as this reflects the range of change
beyond which to further improvement or deterioration may be detected. As screening tools are not,
in general, used to monitor change, but rather to detect the presence/absence of a particular condition
or construct, this criterion is of lesser import in this instance.
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Precision Number of rating or response options/gradations/distinctions within the scale items.

Interpretability Are the results of assessment meaningful? Are there consistent definitions or classifications associated
with scale scores? Are there appropriate normative scores available for comparison?
Acceptability Is assessment acceptable to the patient or does administration represent burden to the patient?
Feasibility What are the administrative costs associated with the tool (effort, expense, training and equipment
requirements and possible disruption to staff and to clinical care routines)?

*Salter et al. [14].

and time, the provision of speech and language years 1960–2005 using the following keywords
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services may be minimal in many areas, thereby
limiting the number of patients who can be assessed
in full by a speech language pathologist [8, 9].
In these circumstances, a routine screening test
administered by another healthcare professional may
be an invaluable tool in the identification of patients
with potential communication problems [10]. These
patients can then be referred for a comprehensive
assessment and initiation of treatment by the
appropriate speech language professional.
While screening assessments do not provide
detailed descriptions of specific language deficits
or allow for a differential diagnosis of language
disorders, they do represent a quick and efficient
means to determine the presence or absence of
language deficits, particularly among patients who
may be unable to tolerate a lengthy evaluation
process. In addition to identifying patients for
referral and treatment, screening tools may be
helpful in assessing basic abilities and monitoring
progress until such time as a more comprehensive
assessment may be completed [11, 12]. The present
study presents an evaluation of the psychometric
and administrative properties of screening tools for
aphasia found within the stroke rehabilitation
research literature.
Methods
Searches were conducted of the PubMed, Web of
Science and CINAHL electronic databases for the
to identify screening tools used within the stroke
rehabilitation literature: screening, assessment, aphasia
and stroke. Articles containing information on the
development, reliability and/or validity of identified
screening assessment tools were selected for inclu-
sion in the present study. The reference lists of
selected articles were hand-searched to identify
additional articles for inclusion in the study. Only
information gained from research, freely available
in the public domain was considered for inclusion.
Identified tools were assessed for reliability and
validity as well as for practical, administrative
qualities such as interpretability, acceptability
and feasibility based upon the evaluation criteria
recommended by Fitzpatrick et al. [13] (Table I).
Evaluation criteria and standards used have been
outlined in detail elsewhere by Salter et al. [14].
Results
A total of six screening devices with information to
support some psychometric evaluation were identi-
fied. Features of each measure (areas of assessment/
sub-scales, total score, time required for administra-
tion, equipment requirements and the availability of
norms to aid in interpretation of scores) are provided
in Table II. This information is supplemented by
a description of each measure, as well as a brief
discussion of the strengths and limitations associated
with the use of each instrument. Measurement
characteristics of each tool (reliability, validity,
 Identification of aphasia post stroke 561

Table II. Description of screening tools for aphasia.

Total Time Norms

Tool Sub-scales score required Equipment required available

Acute Aphasia Attention/orientation to communica- 50 10 min 5 items readily available in No

Screening Protocol [11]
tion (5 items), Auditory compre- the test environment
hension (15 items), Expressive
abilities (20 items), Conversational
style (4 items; 3 are rated using a
3-point scale)

Frenchay Aphasia Comprehension (out of 10), Verbal 30 3–10 min One double-sided stimulus Yes
Screening Test [15] expression (out of 10), Reading card and 5 written
(out of 5), Writing (out of 5) instructions

Mississippi Aphasia Naming (5 items), Automatic speech 100 5–10 min One photograph, five No
Screening Test [19] (5 items), Repetition (5 items), written instructions,
Yes/no accuracy (10 items), Object five common objects
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recognition (5 items), Following

verbal instructions (5 items),
Reading instructions (5 items),
Verbal fluency (1 item),
Writing/spelling to dictation
(5 items)
Reitan-Indiana Aphasia 32 items, no sub-scales 77 [25] n/a Written sentences/com- Yes
Screening Examination [24] mands, common object
(key) [25]

ScreeLing [7] Semantics (24 items), Phonology 72 15 min n/a No

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(24 items), syntax (24 items)

Ullevaal Aphasia
Screening Test [31]
Expression, Comprehension, None 5–15 min A copy of the painting ‘self- No
Repetition, Reading, Reproduction portrait’ by Theodor
of a string of words, Writing, Kittelsen, reading cards,
Free Communication six objects (cup, comb,
pen, spoon, coin
toothbrush)

sensitivity/specificity and whether the tool has been
evaluated for use in the assessment of persons with
stroke) are also summarized in table format
(Table III).
Acute aphasia screening protocol (AASP)
Published in 1989, the Acute Aphasia Screening
Protocol (AASP) was designed to provide an
objective assessment of language deficits in acute
patients who might be unable to tolerate a lengthier
examination. In addition, the information from
the AASP might be used as an indicator of early
progress [11]. The test assesses language ability
in four general areas; attention or orientation to
communication, auditory comprehension, expressive
abilities and conversational style (see Table II).
Items/tasks were selected to represent commu-
nication functions generally included in the assess-
ment of aphasia and are similar to items appearing
in longer, more comprehensive assessment batteries
[11]. Most items are rated in a yes/no format (where
yes ¼ 1 and no ¼ 0) with the exception of ‘conversa-
tional style’, in which conversational attributes
such as output, information and production effort
are rated based on a brief conversation with the
patient using a 3-item checklist (minimal, normal or
excessive). Scores from each sub-test are summed
to provide a total score out of 100 (see Table II),
which is then expressed as a percentage. The total
score is intended as an index of aphasia
severity. Measurement properties of the AASP are
summarized in Table III.
Advantages and limitations. While not strictly a test
to determine the presence of aphasia, the AASP is
short and can be administered easily at bedside using
only readily available objects for stimuli. Although
the AASP appears to be a generally reliable and valid
instrument (see Table III), reported inter-observer
reliability was relatively low for the conversational
styles sub-scale. This could be attributed to the more
subjective nature of the rating system used for that
sub-scale [11]. It should be noted that information
on the measurement properties and clinical utility of
this scale is confined to the results of a single study
by the scale authors.
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562
K. Salter et al.

Table III. Measurement properties of screening tools for aphasia.

Tool Reliability Validity Sensitivity/specificity Tested for stroke?

Acute Aphasia Test–re-test: 0.94–1.00 [11] Concurrent: WAB quotient correlated with AASP n/a Yes
Screening Protocol Inter-observer: 0.70–1.00 [11] score (r ¼ 0.93). Sub-scales of AASP correlated
strongly with corresponding areas of WAB
(r ¼ 0.61–0.95) [11]

Frenchay Aphasia Test–re-test: k ¼ 1.00 Construct: FAST scores associated with Barthel Using age stratified cut-off scores, Yes
Screening Test [47], W ¼ 0.97 [15] Index (r ¼ 0.59) [8] overall sensitivity ¼ 87%, and
Inter-observer: W  0.97 Concurrent: FAST scores correlated with Functional specificity ¼ 80% [15];
[15]; 93% agreement [48] Communication Profile at
15 days post-stroke Al-Khawaja et al. [8] also reported
(r ¼ 0.87) and in patients with chronic aphasia overall sensitivity ¼ 87% and spe-
(r ¼ 0.96) [15]; SST & FAST scores correlated cificity ¼ 80% using age-stratified
(0.86) [8]; total FAST scores correlated with cut-off scores. Using a cut-off score
FCT & shortened Minnesota Test for of <25/30 to identify the presence
Differential Diagnosis of Aphasia (0.73 & 0.91, of aphasia, at day 1 & day 7 post-
respectively) [16] stroke, sensitivity ¼ 96% & 100%
Convergent: Receptive & expressive skills on and specificity ¼ 61% & 79%,
Sheffield Screening test were associated with respectively, using only receptive &
corresponding FAST scales (0.74 & 0.92, expressive sub-tests [9]
respectively) [8]; correlations between
sub-tests of MTDDA and FAST ranged
from 0.70–0.82 [16]
Mississippi Aphasia n/a Construct (known groups): Significant differences n/a Yes
Screening Test were reported for scores between patients with
left hemisphere vs. right hemisphere lesions vs.
non-patients on all 9 sub-scales as well as both
indices and total scores—on all measures,
patients with left hemisphere lesions performed
worse than non-patients (p < 0.003) as did those
with right hemisphere lesions (p < 0.03)—accu-
rate prediction of group membership was 74.2%,
69.9% and 71% using the sub-tests, indices and
total score, respectively [19]
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Reitan-Indiana Inter-observer: Single item Construct: Factor analysis identified presence of Ernst [27] identified a cut-off point of Yes
Aphasia Screening coefficients for all 2 factors: language abilities and sensorimotor 7 for the identification of aphasia in
Examination but 4 items were >0.80 coordination [29] a group of healthy respondents
for verbal components Convergent: Verbal scores on the ASE correlated aged 65–75. Neither sensitivity and
r ¼ 0.98 and for with verbal comprehension scale of WAIS specificity nor positive and negative
spatial r ¼ 0.97 [25] (r ¼ 0.73) and visuospatial scores on the WAS predictive values were reported.
correlated with spatial scores on the ASE
(r ¼ 0.49) [25]
ScreeLing n/a n/a Using a cut-off score of 65/72: sensi- Yes
tivity ¼ 86%; specificity ¼ 96%;
AUC ¼ 0.92; The sensitivity of
each sub-test was substantially
lower, though the specificity asso-
ciated with each was 100% [7]

Ullevaal Aphasia n/a Concurrent: Coefficient of agreement between clas- PPV ¼ 67%, NPV ¼ 93%, sensitivity Yes
Screening Test sification derived from the UAS and assessment ¼ 0.75, specificity ¼ 0.90 [31]
by a speech language pathologist using the
Norwegian Basic Aphasia assessment was kw ¼
0.83–86% agreement for identification of the
presence of language disability between UAS and
speech language pathologist [31]
Identification of aphasia post stroke
563
 564 K. Salter et al.

Frenchay aphasia screening test (FAST) clinical examination, suggesting that administration
of the screening test provides no real advantage over
First published in 1987 [15], the FAST was created
the careful examination of an experienced clinician.
to provide healthcare professionals working with
A significant inverse relationship between age and
patients who might have aphasia with a quick and
FAST score has been reported [9]. Although
simple method to identify and gauge language
stratified cut-offs and normative data are available
deficit. The FAST was intended to be used as a
for both the complete and shortened versions of the
screening device to identify those patients having
FAST for three age groups; 60 years, 61–70 years
communication difficulties who should be referred
and 71 years, this is based on the assessment of a
for a more detailed evaluation performed by a speech
small sample (n ¼ 123) of normal individuals aged
and language pathologist [12, 15, 16].
21–81þ [15, 18]. As the representation of the very
The FAST assesses language in four major areas:
old within the normative sample was limited, it has
comprehension, verbal expression, reading and
been recommended that test scores be interpreted
writing (see Table II). Testing is focused around a
with caution and the cut-off point signifying the
single, double-sided stimulus card depicting a scene
presence of language difficulties in this group be
on one side and geometric shapes on the other and
lowered to avoid the incorrect classification of very
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five written sentences. All instructions or item tasks

presented to the respondent are of graded length
and difficulty. Points are awarded based on the
correctness or completeness of response. Scores
from each test area are summed to provide a total
score. It is possible to reduce administration time
by administering only the first two sections of the
test (comprehension and expression) for a total
combined score of 20. The classification sensitivity
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elderly subjects [9].
Mississippi aphasia screening test (MAST)
The Mississippi Aphasia Screening Test (MAST)
was published in 2002. It was developed as a brief,
repeatable screening measure suitable for adminis-
tration at bedside or in a variety of clinical settings
by a variety of healthcare providers [19, 20]. The

of this shortened version of the FAST is reported
to be similar to that reported for the complete
assessment [15]. Measurement properties of the
FAST are summarized in Table III.
Advantages and limitations. One of the best known
and most thoroughly evaluated screening measures,
the FAST is both quick and simple to administer.
Administration of the comprehension and expres-
sion sub-tests alone provides an option for an
abbreviated screening. This could be most useful
for patients who are unable to tolerate longer testing
procedures. The FAST has been reported to be
reliable when used during both the acute and post-
acute periods post-stroke [8, 15] and shows good
concurrent validity when evaluated against
assessments of both impairment and function
(see Table III). In addition to identifying the
presence of language deficits, FAST scores have
been used as a way to provide a quick snapshot of
change over time [15]. While repeated administra-
tion of the FAST demonstrated significant change
in the expected direction, the responsiveness of the
FAST to change has not been evaluated in more
detail.
While use of the FAST has been reported to have
good classification sensitivity, the specificity of the
FAST appears to be adversely affected by the
presence of visual field deficits, visual neglect or
inattention, illiteracy, deafness, poor concentration
or confusion [8, 15, 17]. O’Neill et al. [9] reported
lower specificity associated with FAST than with
MAST may be used in serial assessments in order
to track patient progress without the resource and
patient burden associated with the administration of
lengthy comprehensive language batteries [19, 20].
The MAST provides a survey of a broad range of
language skills and, indeed, the range of language
skills assessed by the MAST is greater than that of
either the AASP or FAST (see Table II). Scale items
or tasks were generated by a team of neuropsychol-
ogists, physicians and speech language pathologists.
In all sub-scales, with the exception of verbal
fluency, two points are awarded for each correct
response. In the verbal fluency sub-scale, points are
rewarded based on the number of intelligible words
produced by the respondent in a 10-second period.
Scores from each item are summed to provide
sub-scale scores, which are in turn summed to
provide either a total score (out of 100) or one of
two index scores (receptive and expressive language,
each out of 50) (see Table II). Measurement
properties of the MAST are summarized in
Table III.
Advantages and limitations. The MAST is both
simple and brief. It can be administered by any
experienced healthcare professional in a variety of
clinical settings [19]. While the test appears to have
acceptable construct validity, information regarding
its measurement properties is very limited (see
Table III). No evaluation of reliability or assessment
of the utility of the MAST in accurately identifying
the presence or absence of aphasia could be located.

Given that some test items require visual scanning
of presented stimuli, test results may be negatively
affected by the presence of visual deficits, particu-
larly left neglect [19]. In addition, the scale
authors identified a significant association between
test scores and age, education and handedness in a
non-patient group of study participants.
Reitan-Indiana aphasia screening
examination (ASE)
Originally published as the 51-item Halstead and
Wepman Aphasia Screening test [21] in 1949,
the ASE has undergone considerable revision.
In its present form, it is a 32-item test
incorporated into the comprehensive Halstead–
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Reitan Neuropsychological Battery [22–24]. As a
stand-alone screening tool, the Reitan-Indiana
Aphasia Screening Examination (ASE) provides a
brief, quantitative assessment of basic language
encompassing the areas of reception, expression
and comprehension [25] (see Table II).
The 32 items comprising the ASE receive a score
of 0 or 1 based on the absence or presence of
impaired responding [26]. Points are awarded for
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impaired rather than correct responses. Various
scoring criteria have been published. Formal scoring
criteria were published by Russell et al. [23] and the
structured format for scoring proposed by Barth
et al. [25] incorporated the use of the 5-point item
rating scale suggested by Russell et al. Item scores
are summed to provide a total score out of 77
(see Table II). Measurement properties of the ASE
are summarized in Table III.
Advantages and limitations. ‘Tentative’ normative
standards for elderly respondents and a description
of ‘typical performance’ were published by Ernst
[27], thereby enhancing the interpretability of ASE
test results. However, the size of the normative
sample was small, consisting of 85 respondents aged
65–75 [27]. While the test appears to be both
reliable and valid, this assessment is based on the
limited amount of information readily available in
the published research literature.
It has been reported that level of education,
IQ, gender and ethnicity are significantly
associated with performance on the Halstead-
Reitan Neuropsychological Test Battery among
individuals with no neurological impairment
[27, 28]. Williams and Shane [29] reported a
significant association between level of education
and test score in several areas of the ASE as did
Ernst [27]. A strong association between
intelligence, as measured on the WAIS-R, and ASE
scores when administered as part of the larger
Halstead–Reitan Neuropsychological Battery, has
Identification of aphasia post stroke 565
also been demonstrated [30]. The influence of
these variables could result in misclassification of
individuals and should be taken into consideration
in the interpretation of test results.
Early problems with scoring have been addressed
through the development of more structured scoring
procedures; however, even when the standard
scoring criteria are applied it would appear as
though several items remain difficult to score and
demonstrate lower levels of reliability [25]. Barth
et al. [25] suggested that the reliability of the ASE
would benefit from more explicit administration
and scoring instructions, particularly for the more
difficult-to-score items. It has been recommended
that the ASE be administered by well-trained
clinicians [29].
The ASE, when scored via the Russell et al. [23]
system, provides only a global score. There is no
scaling for language skills in various areas, although
Williams and Shane [29] reported the presence of
two factors on factor analysis (language abilities and
sensorimotor coordination), which supports the use
of multi-scaled scoring.
ScreeLing
Published in 2003, the ScreeLing was developed
for use as a brief screening test to assess language
impairments at the semantic, phonological and
syntactic levels. The test was intended to identify
the presence of aphasia as well as provide a brief
linguistic profile to serve as an aide in determining an
appropriate course of referral and intervention [7].
The ScreeLing assesses deficits in three sub-tests
each consisting of 24 items in four areas (Table II).
Items are scored as either correct (1 point) or
incorrect (0 points). Item scores are summed to
provide sub-test scores, which may, in turn,
be summed to provide a global score [7]. Reported
measurement properties of the ScreeLing are
summarized in Table III.
Advantages and limitations. The ScreeLing provides
a brief linguistic profile in addition to a global score
as a more informative means to guide the process
of referral and initial intervention. It may be used
during the acute period post stroke although
Doesborgh et al. [7] reported that between
2–11 days following stroke, 39% of patients could
not be assessed due to severity of illness, visuospatial
difficulties or confusion. As is the case with many
of the other screening tests identified in the
literature, there appears to be very little information
available about the reliability, validity or practical
application of the ScreeLing.
 566 K. Salter et al.
Ullevaal aphasia screening test (UAS)
Published in 1999, the Ullevaal Aphasia Screen Test
(UAS) was intended to be a simple method used
by nurses to detect aphasia in the acute stage of
stroke [31]. Assessment includes seven aspects
of language; expression, comprehension, repetition,
reading, reproduction of a string of words, writing
and free communication (see Table II).
Respondents are shown a painting and given a set
of standardized instructions of differing lengths and
difficulty relating to the test stimulus. Responses are
assessed on the basis of completeness and pace
[31, 32]. Unlike the other tools reviewed here, no
global or sub-test scores are generated. Instead, each
of the seven assessed aspects of language is rated as
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normal or impaired and respondents are placed
into one of four possible outcome categories
based on overall performance; normal language or
mild, moderate or severe language disorder [31].
Measurement properties of the UAS are summarized
in Table II.
Advantages and limitations. Non-speech-language
professionals can administer the UAS quickly and
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easily. The test appears to be well tolerated by
patients in the acute phase post-stroke [31] who
may be too ill to tolerate extensive assessments.
Little training appears to be required to administer
the test with results similar to those reported by
Thommessen et al. [31].
While the reported specificity and negative pre-
dictive value of the UAS were high, sensitivity and
positive predictive value were both somewhat low.
The UAS was not designed to assess articulatory
disturbances or to aid in differentiating these from
aphasia. Therefore, results of the UAS may include
patients with language disturbances who are not
truly aphasic [31]. Although the scoring format for
each item, as presented by the authors in the original
publication of the scale, consists of rating responses
as either impaired or normal and using these ratings
to place respondents in a descriptive category of
overall performance, a later publication reports a
single total UAS score ranging from 0–52 [32].
Unfortunately, the source or method for this
derivation was not provided. As is the case for the
majority of screening tools included in the present
study, little information is available with regard to
the measurement properties or practical application
of the UAS in a clinical setting.
Discussion
Reliability and validity are measurement
properties considered essential to the evaluation of
assessment tools. Evaluation of the tools identified in
the present study was hindered by a dearth of
published information freely available within the
stroke research literature. Of all the tools reviewed,
the FAST is the most thoroughly evaluated in terms
of reliability and validity. While evaluations of
reliability and validity provide the potential user
with an indication of how well a given assessment
tool might function within a particular sample or for
a given purpose [13, 33], these properties are not
fixed and may vary depending upon the respondent
population. As noted in Table III, all of the
screening tools described here have been evaluated
for use within populations of individuals who had
experienced stroke.
It has been well documented that test performance
on psychometric evaluation is influenced by associa-
tion with a number of demographic variables such as
age, gender, IQ, ethnicity and level of education or
literacy. Low levels of education, in particular, may
have an adverse effect on the result of neuropsycho-
logical tests, especially those focused on the assess-
ment of language [28, 34–36]. Despite evidence
supporting significant interaction between level of
education and test performance and recommenda-
tions that test scores be interpreted in light of
respondents’ educational background, few tests offer
formal adjustments for the influence of education
[36, 37]. In the present review, evaluations of
potential test score biases are available for only the
FAST [8, 15, 17], MAST [19] and ASE [27, 29, 30]
scales. Results from those studies that did examine
the influence of education or illiteracy on test results
suggested that low levels of education could have an
adverse effect on test scores and, therefore, result
in the misclassification of respondents. Although
normative data are available for both the FAST and
the ASE; neither are adjusted for level of education.
The FAST norms are stratified for age, while the
ASE data is derived from a population sample of
individuals aged 65–75 only.
Selection of an appropriate assessment tool for any
given task requires a careful analysis of the purpose
for assessment, as well as the acceptability and
feasibility of the assessment within the desired
setting. Ideally, screening assessments should be
quick and simple to administer, representing little
patient burden and resource expenditure. It should
be possible for a variety of healthcare professionals to
administer the test with little or no training required.
The results of screening should reasonably identify
the presence or absence of a given condition. All of
the tools presented here appear to be both brief and
simple to administer. Most, with the exception of
the Reitan-Indiana Aphasia Screening Examination,
appear to require minimal training and experience,
although there is little information available in the

research literature regarding the clinical application
of any of these tools. The FAST, MAST and
UAS were all created specifically for use by
healthcare professionals outside of the speech and
language discipline. Of these three instruments,
there is published information regarding the useful-
ness of the instrument in terms of identifying
the presence or absence of language deficits for
only the FAST and UAS. The sensitivity of the
FAST is superior to the UAS (87% vs. 75%), while
the UAS boasts higher levels of specificity (80% vs.
90%), although the values reported for the UAS
are based upon a scoring system for which a
description could not be located within the
published literature. It should also be noted that
Brain Inj Downloaded from informahealthcare.com by University of Glasgow on 04/02/13
no agreed upon standard exists by which to judge the
adequacy of sensitivity and specificity as an index of
validity [38].
It should be noted that a brief review of available
texts [18, 39] revealed the existence of numerous
other screening tools such as the Bedside Evaluation
Screening Test [40], Sheffield Screening Test for
Acquired Language Disorders [41], Sklar Aphasia
Scale [42], The Aphasia Screening Test [43], Quick
For personal use only.
Assessment for Aphasia [44] and the Aphasia
Language Performance Scales [45]. When the
research literature was searched for articles evaluat-
ing the measurement properties of these scales, none
could be located for any but the Sheffield Screening
Test for Acquired Language Disorders (SST). Two
articles evaluating the SST were retrieved; however,
neither contained an adequate description of the
test, its administration or scoring.
Conclusion
Clearly, routine screening for aphasia would
require the use of reliable and well-validated
assessment tools. Based on the present review, it
is apparent that while there are a variety of tools
from which to choose, there is little freely
available published information with which to
evaluate the measurement properties and clinical
utility of these instruments. The most thoroughly
evaluated and widely used measure among those
identified here is the Frenchay Aphasia Screening
Test. The FAST appears reliable, valid and
sufficient for the identification of the presence of
language deficits as part of a two-step process of
screening and referral, although the reported
specificity of the test is somewhat low (80%).
To promote an informed process of selection of
assessment tools, further evaluation of the
measurement properties and clinical utility of
available screening tools is recommended.
Identification of aphasia post stroke 567
References
1. Berthier ML. Poststroke aphasia: Epidemiology, pathophy-
siology and treatment. Drugs in Aging 2005;22:163–182.
2. Ferro JM, Mariano G, Madureira S. Recovery from aphasia
and neglect. Cerebrovascular Disease 1999;9(Suppl 5):6–22.
3. Pedersen PM, Vinter K, Olsen TS. Aphasia after stroke:
Type, severity and prognosis. The Copenhagen aphasia
study. Cerebrovascular Disease 2004;17:35–43.
4. Bhogal SK, Teasell R, Speechley M. Intensity of aphasia
therapy, impact on recovery. Stroke 2003;34:987–993.
5. Teasell R, Bitensky J, Salter K, Bayona NA. The role of
timing and intensity of rehabilitaiton therapies. Topics in
Stroke Rehabilitation 2005;12:46–57.
6. Geis C, Grissom S. Rehabilitation medicine issues in acute
stroke: Prevention of common complications, facilitation
of recovery, and assessment of rehabilitation potential.
The Neurologist 1997;3:322–330.
7. Doesborgh SJ, van de Sandt-Koenderman WM, Dippel DW,
van Harskamp F, Koudstaal PJ, Visch-Brink EG. Linguistic
deficits in the acute phase of stroke. Journal of Neurology
2003;250:977–982.
8. Al-Khawaja I, Wade DT, Collin CF. Bedside screening for
aphasia: A comparison of two methods. Journal of Neurology
1996;243:201–204.
9. O’Neill PA, Cheadle B, Wyatt R, McGuffog J, Fullerton KJ.
The value of the Frenchay Aphasia Screening Test in
screening for dysphasia: Better than the clinician? Clinical
Rehabilitation 1990;4:123–128.
10. Riepe MW, Riss S, Bittner D, Huber R. Screening for cognitive
impairment in patients with acute stroke. Dementure and
Geriatric Cognitive Disorders 2004;17:49–53.
11. Crary MA, Haak NJ, Malinsky AE. Preliminary psychometric
evaluation of an acute aphasia screening protocol.
Aphasiology 1989;3:611–618.
12. Enderby PM, Wood VA, Wade DT, Langton Hewer R.
Aphasia after stroke: A detailed study of recovery in the
first 3 months. International Rehabilitation Medicine
1987;8:162–165.
13. Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluation of
patient-based outcome measures for use in clinical trials.
Health Technology Assessment 1998;2:1–74.
14. Salter K, Jutai JW, Teasell R, Foley NC, Bitensky J. Issues
for selection of outcome measures in stroke rehabilitation:
ICF body function. Disability and Rehabilitation
2005;27:191–207.
15. Enderby PM, Wood VA, Wade DT, Langton Hewer R.
The Frenchay Aphasia Screening Test: A short, simple test
for aphasia appropriate for nonspecialists. International
Journal of Rehabilitation Medicine 1987;8:166–170.
16. Enderby P, Crow E. Frenchay Aphasia Screening Test:
Validity and comparability. Disability and Rehabilitation
1996;18:238–240.
17. Gibson L, MacLennan WJ, Gray C, Pentland B. Evaluation
of a comprehensive assessment battery for stroke patients.
International Journal of Rehabilitation Research
1991;14:93–100.
18. Spreen O, Risser AH. Assessment of aphasia. New York:
Oxford University Press; 2003.
19. Nakase-Thompson R, Manning E, Sherer M, Yablon SA,
Gontkovsky SLT, Vickery C. Brief assessment of severe
language impairements: Initial validation of the Mississippi
aphasia screening test. Brain Injury 2005;19:685–691.
20. Nakase-Thompson R, Manning E, Sherer M, Yablon SA,
Vickery C, Harris C, Dickson S. Bedside screen of language
disturbance among acute care admissions: Initial psycho-
metrics of the Mississippi Aphasia Screening Test. Archives
of Clinical Neurospsychology 2002;17:848.
 568 K. Salter et al.
21. Halstead W, Wepman J. The Halstead-Wepman aphasia
screening test. Journal of Speech and Hearing Disorders
1949;14:9–15.
22. Reitan RM, Davidson LA. Clinical neuropsychology:
Current status and applications. New York: Winston/
Wiley; 1974.
23. Russell E, Neuringer C, Goldstein G. Assessment of brain
damage: A neuropsychological key approach. New York:
Wiley-Interscience; 1970.
24. Reitan RM, Wolfson D. The Halstead-Reitan neuropsycho-
logical test battery: Theory and clinical interpretation.
Tucson, AZ: Neuropsychology Press; 1985.
25. Barth JT, MacCiocchi SN, Giordani B, Berent S,
Boll TJ. Interrater reliability and prediction of verbal
and spatial functioning with a modified scoring system
for the Reitan-Indiana Aphasia Screening Examination.
International Journal of Clinical Neuropsychology
1984;6:135–138.
26. Wheeler L, Reitan R. The presence and laterality of brain
Brain Inj Downloaded from informahealthcare.com by University of Glasgow on 04/02/13
damage predicted from responses to a short aphasia screening
test. Perceptual and Motor Skills 1962;15:783–799.
27. Ernst J. Language, grip strength, sensory-perceptual, and
receptive skills in a normal elderly sample. The Clinical
Neuropsychologist 1988;2:30–40.
28. Leckliter IN, Matarazzo JD. The influence of age, education,
IQ, gender, and alcohol abuse on Halstead-Reitan
Neuropsychological Test Battery performance. Journal of
Clinical Psychology 1989;45:484–512.
29. Williams JM, Shane B. The Reitan-Indiana Aphasia
Screening Test: Scoring and factor analysis. Journal of
For personal use only.
Clinical Psychology 1986;42:156–160.
30. Warner MH, Ernst J, Townes BD, Peel J, Preston M.
Relationships between IQ and neuropsychological measures
in neuropsychiatric populations: Within laboratory and
cross-cultural replications using WAIS and WAIS-R.
Journal of Clinical and Experimental Neuropsychology
1987;9:545–562.
31. Thommessen B, Thoresen GE, Bautz-Holter E, Laake K.
Screening by nurses for aphasia in stroke—the Ullevaal
Aphasia Screening (UAS) test. Disability and Rehabilitation
1999;21:110–115.
32. Sveen U, Thommessen B, Bautz-Holter E, Wyller TB,
Laake K. Well-being and instrumental activities of daily
living after stroke. Clinical Rehabilitation 2004;267:274.
33. Lorentz WJ, Scanlan JM, Borson S. Brief screening
tests for dementia. Canadian Journal of Psychiatry
2002;47:723–733.
34. Ardila A, Ostrosky-Solis F, Rosselli M, Gomez C. Age-
related cognitive decline during normal aging: The complex
effect of education. Archives of Clinical Neuropsychology
2000;15:495–513.
35. Neils J, Baris JM, Carter C, Dell’aira AL, Nordloh SJ,
Weiler E, et al. Effects of age, education, and living
environment on Boston Naming Test performance. Journal
of Speech & Hearing Research 1995;38:1143–1149.
36. Osterweil D, Mulford P, Syndulko K, Martin M. Cognitive
function in old and very old residents of a residential facility:
Relationship to age, education, and dementia. Journal of the
American Geriatrics Society 1994;42:766–773.
37. Spreen O, Strauss E. A compendium of neuropsychological
tests: Administration, norms and commentary. 2nd ed.
New York: Oxford University Press; 1998.
38. Riddle DL, Stratford PW. Interpreting validity indexes for
diagnostic tests: An illustration using the Berg Balance Test.
Physical Therapy 1999;79:939–948.
39. Murray LL, Chapey R. Assessment of language disorder in
adults. In: Chapey R, editor. Language intervention strategies
in aphasia and related neurogenic communciation disorders.
Baltimore, MD: Lippincott Williams and Wilkins; 2001.
pp 55–119.
40. Fitch-West J, Sands ES. Bedside evaluation screening test
(BEST2). 2nd ed. Austin, TX: Pro-Ed; 1998.
41. Syder D, Body R, Parker M, Boddy M. Sheffield screening
test for acquired language disorders. Manual, Windsor, UK:
Nfer-Nelson; 1993.
42. Sklar M. Sklar aphasia scale. Los Angeles, CA: Western
Psychological Services; 1983.
43. Whurr R. The aphasia screening test. 2nd ed. San Diego, CA:
Singular Publishing Group; 1996.
44. Tanner DC, Culbertson W. Quick assessment of aphasia.
Oceanside, CA: Academic Communication Associates; 1999.
45. Keenan JS, Brassell EG. Aphasia language performance
scales. Murfreesboro, TN: Pinnacle Press; 1975.
46. Finch E, Brooks D, Stratford PW, Mayo NE. Physical
rehabilitations outcome measures. A guide to enhanced
clinical decision-making. 2nd ed. Toronto, Ontario:
Canadian Physiotherapy Association; 2002.
47. Philp I, Lowles RV, Armstrong GK, Whitehead C.
Repeatability of standardized tests of functional impairment
and well-being in older people in a rehabilitation setting.
Disability and Rehabilitation 2002;24:243–249.
48. Sweeney T, Sheahan N, Rice I, Malone J, Walsh JB,
Coakley D. Communication disorders in a hospital elderly
population. Clinical Rehabilitation 1993;7:113–117.