Frenchay Aphasia Screen Test (FAST)

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Frenchay Aphasia Screening Test (FAST) was developed to provide healthcare professionals working with patients who might have aphasia with a quick and simple method to identify the presence of a language deficit. The FAST was intended to be used as a screening device to identify those patients having communication difficulties who should be referred for a more detailed evaluation performed by a speech and language pathologist.

In-Depth Review

Purpose of the measure

The Frenchay Aphasia Screening Test (FAST) was developed to provide healthcare professionals working with patients who might have aphasia with a quick and simple method to identify the presence of a language deficit. The FAST was intended to be used as a screening device to identify those patients having communication difficulties who should be referred for a more detailed evaluation performed by a speech and language pathologist.

Available versions

The FAST was first published in 1987 by Enderby, Wood, Wade, and Hewer. This version has 4 subscales (comprehension; verbal expression; reading; writing) and is scored out of a total of 30 points.

Features of the measure

Items:
The FAST assesses language in four major areas: comprehension, verbal expression, reading, and writing. Testing is focused around a single, double-sided stimulus card depicting a scene on one side and geometric shapes on the other and five written sentences. All instructions or item tasks presented to the respondent are of graded length and difficulty.

The instructions for administering each section of the FAST are as follows:

Comprehension (out of 10). Show patient the card with the river scene and say: ‘Look at the picture. Listen carefully to what is said and point to the things I tell you to.

(a)River scene
Practice item: “Point to the river“. Do not score this item. Repeat until patient understands what is required.
1. “Point to a boat”
2. “Point to the tallest tree”
3. “Point to the man and point to the dog”
4. “Point to the man’s left leg and then to the canoe”
5. “Before pointing to a duck near the bridge, show me the middle hill”

(b)Shapes
Practice item: “Point to the circle“. Repeat until patient understands task.
1. “Point to the square”
2. “Point to the cone”
3. “Point to the oblong and the square”
4. “Point to the square, the cone and the semicircle”
5. “Point to the one that looks like a pyramid and the one that looks like a segment of orange”

Verbal expression (out of 10).
(a) Show the patient the river scene and say: ‘Tell me as much about the picture as you can.’ If the patient does not appear to understand, say: ‘Name anything you can see in the picture.’

(b) Remove picture card from view and inform patient that you are now going to attempt something a little different. Ask the patient to name as many animals as he/she can think of in 1 minute. If the patient appears doubtful, explain that you want the names of any kind of animal, wild or domestic, and not just those which may have been seen in the picture. Start timing with the stopwatch as soon as the patient names their first animal and allow the patient to list for 60 seconds before stopping the task.

Reading (out of 5). Check that the patient is wearing their correct eyeglasses for reading purposes. Show the patient the river scene and first reading card. Ask the patient to read the sentence to him/herself, not aloud, and do whatever it instructs him/her to do. Proceed in the same manner with the remaining four reading cards.

Writing (out of 5). Show patient river scene and say: ‘Please write as much as you can about what is happening in the picture’. If the patient does not appear to understand say: ‘Write anything that you can see in the picture’. If their dominant hand is affected, ask the patient to attempt the test with their non-dominant hand. Encourage the patient if he/she stops prematurely. Allow a maximum of 5 minutes to complete this section.

Scoring:
Points are awarded based on the correctness or completeness of the response. Scores from each test area are summed to provide a total score.

How to score comprehension section:
Score 1 point for each item performed correctly. If instructions require repeating, score as an error. Unprompted self-correction may be scored as correct. This section is scored out of a total score of 10 points.

How to score verbal expression section:
The verbal expression section is scored out of a total score of 10 points.

Part (a):

1. unable to name any objects intelligibly
2. names 1 – 2 objects
3. names 3 – 4 objects
4. names 5 – 7 objects
5. names 8 or 9 objects or uses phrases and sentences, but performance not normal (e.g. hesitations, inappropriate comments, etc.)
6. Normal – uses phrases and sentences, naming 10 items

Part (b):

1. None named
2. Names 1 – 2
3. Names 3 – 5
4. Names 6 – 9
5. Names 10 – 14
6. Names 15 or more

How to score reading section:
Score 1 point for each items completed correctly for a total score of 5 points.

How to score writing section:
The writing section is scored out of a total score of 5 points.

1. Able to attempt task but does not write any intelligible or appropriate words
2. Writes 1 or 2 appropriate words
3. Writes down names of 3 objects or a phrase including 2 or 3 objects
4. Writes down names of 4 objects (correctly spelled), or 2 or 3 phrases including names of 4 items
5. Uses phrases and sentences, including names of 5 items, but not considered ‘normal’ performance, e.g. sentence is not integrating people and actions
6. Definitely normal performance, e.g. sentence integrating people and actions

Total score interpretation:
The presence of aphasia is indicated if the patient scores below the following cutoff points:

Age Raw Score

Up to 60

27

61+

25

A significant inverse relationship between age and FAST total score has been reported (O’Neill, Cheadle, Wyatt, McGuffog, and Fullerton, 1990). Although stratified cutoffs and normative data are available for both the complete and shortened versions of the FAST for three age groups; =60 years, 61-70 years and =71 years, this is based on the assessment of a small sample (n=123) of normal individuals aged 21-81. As there was limited representation of the very elderly within the normative sample, it has been recommended that test scores be interpreted with caution and the cutoff point signifying the presence of language difficulties in this group be lowered to avoid the incorrect classification of very elderly patients (O’Neill et al., 1990).

Time:
The FAST takes 3-10 minutes to complete (Enderby et al., 1987).

Subscales:
There are 4 subscales to the FAST: comprehension; verbal expression; reading; writing

Equipment: Completion of the FAST requires the following items:

  • Double-sided stimulus card with attached reading cards
  • Pencil and paper
  • Stopwatch or watch with second hand

Training:
The FAST is suitable for use by general practitioners, junior medical staff, and other non-specialists (Enderby et al., 1987).

Alternative Forms of the FAST

  • Shortened version of the FAST (Enderby, Wood, Wade, Langton Hewer, 1987).
    To reduce administration time, only the comprehension and expression sections of the test can be administered, for a total combined score of 20. A score of 13 or less out of 20 indicates aphasia. The classification sensitivity of this shortened version of the FAST is reported to be similar to that for the complete assessment.

Client suitability

Can be used with: patients with stroke.

Should not be used with:

  • 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 and therefore should be used with caution in patients with these conditions (Enderby, 1987; Al-Khawaja, Wade, & Collin, 1996; Gibson, MacLennan, Gray, & Pentland, 1991).

In what languages is the measure available?

To our knowledge, the FAST is only available in English.

Summary

What does the tool measure? The presence of a language deficit.
What types of clients can the tool be used for? Patients who might have aphasia.
Is this a screening or assessment tool? Screening
Time to administer The FAST takes approximately 3-10 minutes to administer.
Versions Original FAST (This version has 4 subscales comprehension; verbal expression; reading; writing) and is scored out of a total of 20 points; Shortened Version of the FAST (only the comprehension and expression sections are administered).
Other Languages None.
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the FAST.
  • Two studies have examined the test-retest reliability of the FAST. One study reported excellent test-retest using kappa statistics, and one study reported high test-retest using Kendall’s coefficient of concordance (W).
  • One study has examined the inter-rater reliability of the FAST and reported high inter-rater reliability as measured by Kendall’s coefficient of concordance (W).
  • No studies have examined the intra-rater reliability of the FAST.
Validity

Criterion:Concurrent: Excellent correlation between the FAST and the Functional Communication Profile.
Construct: Adequate correlation between the FAST and the Barthel Index.
Convergent/Discriminant validity. Excellent correlations between the comprehension scores on the FAST and the receptive skills on the Sheffield Screening Test for Acquired Language Disorders (SST), between the expression scores on the FAST and the expressive skills on the SST, between the total scores of the FAST and the SST as well as with the total score of the Short Orientation, Memory and Concentration test (SOMC). Excellent correlations between the FAST and the total scores of the Functional Communication Profile and the shortened Minnesota Test for Differential Diagnosis of Aphasia, as well as with subtests of the Minnesota Test for Differential Diagnosis of Aphasia.

Floor/Ceiling Effects No studies have examined the ceiling effects of the FAST.
Sensitivity/Specificity
  • One study compared the FAST to the examination by speech therapists (the “gold standard”) and reported an overall sensitivity of 87% and a specificity of 80%.
  • One study compared the comprehensive and expressive subtests of the FAST to examination by an experienced clinician and reported a sensitivity of 96%-100% and a specificity of 61%-79%.
Does the tool detect change in patients? Although the FAST is intended to be a screening measure, one study reported that the FAST demonstrated significant change in the expected direction.
Acceptability 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 and therefore should be used with caution in patients with these conditions. It has been recommended that when testing the very elderly, test scores be interpreted with caution and the cutoff point signifying the presence of language difficulties be lowered to avoid incorrect classification.
Feasibility The administration of the FAST is quick and simple and can be administered by general practitioners, junior medical staff and other non-specialists and does not require any formal training. FAST stimulus and reading cards are required to complete the measure and can be purchased online. The FAST is simple to score and stratified cutoffs and normative data are available.
How to obtain the tool?

The FAST stimuli and reading cards are available from Wiley at: http://ca.wiley.com/WileyCDA/WileyTitle/productCd-1861564422.html

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the FAST.

Reliability

Test-retest:
Philip, Lowles, Armstrong, and Whitehead (2002) administered the FAST to 50 older patients with repeat administration one or two weeks later by a nurse. Using kappa statistics, the test-retest reliability of the FAST was found to be excellent (kappa = 1.00). A kappa value of 1.0 represents perfect agreement between the two test administration times.

Enderby, Wood, Wade, and Langton Hewer (1987) examined the test-retest reliability of the FAST and reported a high Kendall’s coefficient of concordance (W) (W = 0.97).

Inter-rater:
Enderby, Wood, Wade, and Langton Hewer (1987) examined the inter-rater reliability of the FAST and reported a high Kendall’s coefficient of concordance (W) (W = 0.97).

Sweeney, Sheahan, Rice, Malone, Walsh, and Coakley (1993) examined the inter-rater reliability of the FAST and reported 93% agreement between raters.

Validity

Construct

Al-Khawaja, Wade, and Collin (1995) administered the FAST to 50 patients who were suspected to have aphasia. The FAST had an adequate correlation with the Barthel Index (r=0.59). The authors state that these findings confirm reports that language disorders are associated with the severity of disability (i.e. patients who were incontinent, unable to transfer/walk and required help for personal care, showed more significant speech and language disorders on screening).

Convergent:
Al-Khawaja, Wade, and Collin (1995) examined the relationship between the FAST with the Sheffield Screening Test for Acquired Language Disorders (SST) (Syder, Body, Parker, & Boddy, 1993). The SST is another measure that has been developed to detect the presence of language disorders in adults. The comprehension scores on the FAST had an excellent correlation with receptive skills on the SST (r = 0.74) and with expression scores on the FAST with expressive skills on the SST (r = 0.92). The total scores of the two tests also had an excellent correlation (r = 0.89). In this study, the FAST was also compared to the Short Orientation, Memory and Concentration test (SOMC) (Katzman, Brown, Fuld, Peck, Schechter, and Schimmel, 1983). An excellent correlation between the total score on the FAST and the SOMC (r = 0.86), and between the total scores on the SST and SOMC (r = 0.91) were reported.

Enderby and Crow (1996) examined correlations between the FAST, the Functional Communication Profile and the shortened Minnesota Test for Differential Diagnosis of Aphasia and reported excellent correlations between the FAST and the total scores on both of these measures (r = 0.73 and r = 0.91, respectively). The correlations between the FAST and subtests of the Minnesota Test for Differential Diagnosis of Aphasia ranged from 0.70 to 0.82 and are considered ‘excellent‘.

Criterion

Concurrent:
Enderby, Wood, Wade, and Langton Hewer (1987) examined the concurrent validity of the FAST with the Functional Communication Profile in patients 15 days post-stroke, and in patients with chronic aphasia. Excellent correlations between the two measures were reported for both groups (r = 0.87 and r = 0.96, respectively).

Sensitivity/ Specificity

Al-Khawaja et al. (1995) compared the presence (or absence) of aphasia as confirmed by speech therapists (the “gold standard”) to the FAST and reported that the FAST has an overall sensitivity of 87% and a specificity of 80% using age-stratified cut-off scores.

O’Neill, Cheadle, Wyatt, McGuffog, and Fullerton (1990) compared the comprehensive and expressive subtests of the FAST to clinical examination by an experienced clinician. Using a cutoff score of < 25 out of 30 to identify the presence of aphasia, at one day post-stroke, a sensitivity of 96% and specificity of 61% was reported. At one week post-stroke, a sensitivity of 100% and a specificity of 79% were observed. However, in this study, lower specificity was associated with FAST than with clinical examination, suggesting that administration of the FAST confers no real advantage over the careful examination of an experienced clinician.

Responsiveness

Although the FAST is intended to be a screening measure, the first published study on the FAST examined repeat administration of the test over time and found that the FAST demonstrated significant change in the expected direction (Enderby, 1987). However, the responsiveness of the FAST to change has not been evaluated in more detail.

References

  • Enderby, P. M., Wood, V. A., Wade, D. T., Langton Hewer, R. (1987). The Frenchay Aphasia Screening Test: A short, simple test for aphasia appropriate for nonspecialists. International Journal of Rehabilitation Medicine, 8, 166-170.
  • Enderby, P., Crow, E. (1996). Frenchay Aphasia Screening Test: Validity and comparability. Disability and Rehabilitation, 18, 238-240.
  • Gibson ,L., MacLennan, W. J., Gray, C., Pentland, B. (1991). Evaluation of a comprehensive assessment battery for stroke patients. International Journal of Rehabilitation Research, 14, 93-100.
  • Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., Schimmel, H. (1983). Validation of a short Orientation-Memory-Concentration test of cognitive impairment. Am J Psychiatry, 140, 734-739.
  • O’Neill, P. A., Cheadle, B., Wyatt, R., McGuffog, J., Fullerton, K. J. (1990). The value of the Frenchay Aphasia Screening Test in screening for dysphasia: Better than the clinician? Clinical Rehabilitation, 4, 123-128.
  • Philp, I., Lowles, R. V., Armstrong, G. K., Whitehead, C. (2002). Repeatability of standardized tests of functional impairment and well-being in older people in a rehabilitation setting. Disability and Rehabilitation, 24, 243-249.
  • Salter, K., Jutai, J., Foley, N., Hellings, C., Teasell, R. (2006). Identification of aphasia post stroke: A review of screening assessment tools. Brain Injury, 20(6), 559-568.
  • Sweeney, T., Sheahan, N., Rice, I., Malone, J., Walsh, J. B., Coakley, D. (1993). Communication disorders in a hospital elderly population. Clinical Rehabilitation, 7, 113-117.
  • Syder, D., Body, R., Parker, M., Boddy, M. (1993). Sheffield screening test for acquired language disorders. Manual: Nfer-Nelson.

See The Measure

How to obtain the FAST:

The FAST test manual and stimulus and reading cards can be purchased by accessing the Stass publications website.

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