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Prediction and Prognosis
3
JCPSLP
Volume 18, Number 1 2016
Journal of Clinical Practice in Speech-Language Pathology
Deborah Hersh
(top) and Natalie
Ciccone
Thisarticle
has been
peer-
reviewed
Keywords
aphasia
motivation
predictionsof
potentialfor
recovery
qualitative
research
rehabilitation
speech-
language
pathology
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
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
Predicting potential for
aphasia rehabilitation
The role of judgments of motivation
Deborah Hersh and Natalie Ciccone