Best Guide To Treatment of Underlying Forms (for Aphasia)

In this article, you’ll learn how to do treatment of underlying forms, or TUF, with your speech therapy patients.

TUF is an evidence-based sentence production treatment for agrammatic aphasia.

Research shows that it generalizes outside of the treatment room, improves patients’ ability to say sentences, and improves sentence comprehension (Thompson and Shapiro, 2005).

In this guide you’ll learn:

  • How to do TUF with wh-questions
  • How to make TUF word and picture cards, with examples
  • Where to buy TUF materials

Let’s get started!

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What is Treatment of Underlying Forms?

what is treatment of underlying forms?

Treatment of underlying forms is a therapy technique that treats sentence-level deficits in people with agrammatic aphasia. This is most commonly caused by a stroke or other brain injury.

The goal of TUF is for your patients to say and understand more complex sentences with better sentence structure (syntax). TUF does this by breaking down a sentence into its parts.

And research shows that it works!

Unlike most other aphasia treatments, TUF starts with complex sentences.

Many studies have shown that when patients understand a more complex sentence structure, it generalizes: They can now say and understand simpler sentences in everyday life (Swiderski, 2021).

Treatment of Underlying Forms Manual

treatment of underlying forms manual
Image from Northwestern University

TUF uses word cards and pairs of picture cards to help patients build sentences. You’ll likely need to purchase these if you want to do robust TUF treatment.

You can buy the TUF manual, picture stimuli, and word cards from Northwestern University (home of Cynthia Thompson, the creator of TUF).

Read More Aphasia Articles:

How Does Treatment of Underlying Forms Work?

tuf aphasia

TUF has different treatment protocols, depending on the type of sentence you want your patient to produce.

We’ll cover one of these protocols: The Object-extracted wh-questions (wh movement).

You can learn how to do the other protocols, passive sentences, and object-cleft sentences if you purchase their manual.

TUF uses grammatical terms, like ‘object extracted’ and auxiliary verb.’ Don’t get bogged down by the jargon. If you follow this guide and its examples, all will make sense.

How To Prepare For TUF Treatment

1. Gather Pairs of Picture Cards

For TUF treatment, you’ll use a pair of picture cards. Each picture should have an action with both a subject and an object.

The pair of picture cards will have the same action. But the object and subject will be reversed.

  • In the example pair above, the shared action is chases. While the subject and object of the action are reversed.
  • In Picture 1, the subject is the dog and the object is the boy. The dog chases the boy.
  • In Picture 2, the subject is the boy and the object is the dog. The boy is now chasing the dog.

Gather 10 pairs of picture cards. 

2. Write Down the Subject and Object

  • On separate notecards, write down the subject and the object.
  • Do this for each of the 10 pairs of pictures.

3. Write Down the Verb that Describes the Action

treatment of underlying forms cards
  • On separate notecards, write the verb that describes the action happening in the picture pair.
  • Do this for each of the 10 pairs of pictures.

4. Write These Words/Symbol on 8 Notecards

treatment of underlying forms pdf

On 8 separate notecards, write the following:

  • who
  • what
  • ?
  • it
  • was
  • by
  • seems
  • to have

How To Do TUF With Your Patient

treatment of underlying forms wh questions

Here are the steps to using a pair of picture cards to say sentences.

We’ll use the example of the target sentence the dog is chasing the boy.

You will start with the picture of the semantically reversed pair (the boy is chasing the dog). And move the patient through sentences until they arrive at the target sentence.

Here’s how.

1. Put Down the Reversed Picture

treatment of underlying forms pictures

2. Put Down These Notecards: Subject, Object, Verbs, WHO (and/or WHAT), and ?

treatment of underlying forms example
  • Place the boy (subject notecard), is, chasing (verb notecards), the dog (object notecard) in the correct order.
  • Place the who, ? (and/or what) notecards above the sentence.
  • Point to the verb card and say, “This is chasing. It is the action of the sentence.”
  • Point to the subject card and say, “This is the boy. He is the person doing the chasing.”
  • Point to the object card and say, “This is the dog. It is being chased”.
  • Next, you’ll replace the object with either who or what.

3. Replace the Object with WHO (or WHAT)

  • Say, “The object is who (or what), and they are being chased.”
  • Place ? at the end of the sentence, then ask the patient to read (or repeat) the new sentence.
  • For example: the boy, is, chasing, who, ?

4. Move ‘Is’ to the Beginning of the Sentence (Inverse the Subject and Auxiliary Verb)

is, the boy, chasing, who, ?

5. Move the Wh-morpheme (WHO) to the Sentence-Initial Position

Ask the patient to read (or repeat) the resulting question: who, is, the boy, chasing, ?

6. Re-arrange the Word Cards to Make a Declarative Sentence

  • Re-arrange the word cards to make a declarative sentence again, just like in step 1.
  • But now the dog is the subject and the boy is the object.
  • The notecard positions are now switched to the target sentence (the dog is chasing the boy).

7. Replace the Semantically Reversed Picture with the Target Picture

tuf example picture

Next, you’ll place down the target picture (the dog chasing the boy).

8. Have Them Complete Steps 2-6

treatment of underlying forms example
  • Have your patient complete steps 2-6 with the target picture, switching the positions of the object and subject notecards.
  • Provide assistance, as needed.

9. Return to Step 1 With a New Picture Pair

More Aphasia Approaches

TUF may not be the right (or only) fit for your patient. If so, here are other evidence-based aphasia treatments.

Aphasia approaches for treating syntax:

More aphasia treatment approaches:

More Aphasia Help

Want premade treatment materials? Download the Aphasia Pack for evidence-based aphasia worksheets made for your patients.


  • Poirier, S., Fossard, M., & Monetta, L. (2023). The efficacy of treatments for sentence production deficits in aphasia: a systematic review, Aphasiology, 37:1, 122-142, DOI: 10.1080/02687038.2021.1983152
  • Swiderski, A. M., Quique, Y. M., Dickey, M. W., & Hula, W. D. (2021). Treatment of Underlying Forms: A Bayesian Meta-Analysis of the Effects of Treatment and Person-Related Variables on Treatment Response.
  • Thompson, C. (2001). Treatment of Underlying Forms: A linguistic Specific Approach for Sentence Production Deficits in Agrammatic Aphasia. In R. Chapey (Editor). Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders (4th edition, pp. 605-628). Lippincott Williams & Wilkins.
  • Thompson, C. K., & Shapiro, L. P. (2005). Treating agrammatic aphasia within a linguistic framework: Treatment of Underlying Forms. Aphasiology19(10-11), 1021–1036.
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