JCPSLP Vol 18 No. 1Mar 2016

Prediction and Prognosis

Predicting potential for aphasia rehabilitation The role of judgments of motivation Deborah Hersh and Natalie Ciccone

This paper reviews the role of judgments of motivation by practitioners in predicting recovery post stroke and explores how speech-language pathologists (SLPs) judge motivation in their patients with aphasia. Qualitative data from two separate studies are used to show that judgments of motivation, within a complex mix of factors, are an important aspect of SLPs’ decision- making and may impact on how therapy is offered. We suggest that people with aphasia may be particularly disadvantaged by such judgments and that more discussion and reflection on the issue would be beneficial. T he ability to predict who might benefit from aphasia rehabilitation, who might not, and who is no longer likely to benefit further, is notoriously difficult, but speech-language pathologists (SLPs) have to make such decisions every day. Being able to predict outcomes provides important information for patients and families, for rehabilitation teams in their decisions about the best treatments to offer, and in longer term planning (Gialanella, Bertolinelli, Lissi, & Prometti, 2011). A body of research on recovery of aphasia post stroke suggests that aphasia severity, lesion size, and site have been shown as important for prognosis, while factors such as age, gender, handedness, education, and intelligence are less reliable indicators (Lazar & Antoniello, 2008; Pedersen, Jorgensen, Nakayama, Raaschou, & Olsen, 1995; Plowman, Hentz, & Ellis, 2012). Severe aphasia itself is a predictor of outcome, correlating with lower levels of function (Gialanella et al., 2011). Findings such as these are useful for clinicians, but their application is limited because they do not directly predict recovery in any particular individual patient and may not even be helpful in planning for particular groups of patients. For example, Nouwens et al. (2014) found significant improvements in functional communication in their patients with severe aphasia and suggested that therapy was beneficial for this group even in the acute phase. It is well known that aphasia recovery is remarkably variable (Lazar & Antoniello, 2008) and two people with quite similar lesions might have very different trajectories. To complicate matters further, neurocognitive functioning and personality traits, particularly the degree of positive

or negative affect, may also play a part in coping, level of effort and, ultimately, how well people with aphasia do in rehabilitation (Votruba, Rapport, Whitman, Johnson, & Langenecker, 2013). The presence of depression and low mood, common in people with aphasia post stroke, is also an important consideration, playing a major role in recovery (Code & Hermann, 2003). So if findings on recovery are insufficient to guide clinicians, how do SLPs predict rehabilitation potential in their patients? They regularly have to make complex clinical judgments to drive decision-making. In a recent study exploring the notion of rehabilitation potential in stroke, Burton, Horne, Woodward-Nutt, Bowen, & Tyrrell (2015) ran two focus groups with 12 health care professionals (six occupational therapists, four SLPs, one physiotherapist, and one rehabilitation assistant) and asked them about how they judged this notion. These participants described rehabilitation potential as “visible achievements of goals or outcomes over time” (p. 1957). In practice, they prioritised those who were improving or showing carry-over (even though some measures, such as the Barthel Index, were felt to be insensitive in picking up rehabilitation potential) and moved those who were not towards a maintenance track or less active program. If patients were judged as reaching a “plateau”, they were less likely to receive ongoing rehabilitation (an issue discussed previously by Hersh [1998] specifically in relation to aphasia). For these 12 participants, judgments of rehabilitation potential involved looking first at type of stroke and premorbid history, and then at psychological factors of mood, motivation, and attention. Motivation was associated with insight, pre- stroke memory skills, mental capacity, and attention but the authors noted the prominent role of clinical intuition and clinical experience in these judgments, suggesting they “may be less than reliable” (Burton et al., 2015, p. 1955). Considering that patients with aphasia are at risk for depression or low mood (Votruba et al., 2013), such patients may not make “visible achievements of goals” in the relatively short time allocated to rehabilitation, may find it harder to negotiate common goals with their practitioners (Rohde, Townley-O’Neill, Trendall, Worrall, & Cornwell, 2012), and may be compromised by their language deficits in their attempts to demonstrate motivation to their practitioner. Little has been written specifically about how SLPs make judgments of motivation in patients or clients with aphasia and what the implications might be for service provision. However, there is a helpful literature about the

Thisarticle has been peer- reviewed Keywords aphasia motivation predictionsof potentialfor recovery qualitative research rehabilitation speech- language pathology

Deborah Hersh (top) and Natalie Ciccone

3

JCPSLP Volume 18, Number 1 2016

Journal of Clinical Practice in Speech-Language Pathology