Prognosis of Aphasia Recovery

Prognosis of Aphasia Recovery

Learning Objectives

  • State the information used in determining a prognosis for improvement of communication in a Person with Aphasia (PWA).

Care Settings for Aphasia Recovery

  1. Acute Care Hospital

  2. Inpatient Rehab Hospital

  3. Skilled Nursing Facility

  4. Outpatient Therapy

  5. Home Care

  6. Aphasia Center/Community Group

Understanding Aphasia and Recovery Rates

  • Aphasia is a chronic condition.

  • Statistics:

    • Approximately 2 million people in the US live with aphasia.

    • Less than 10% of those diagnosed with aphasia completely recover at 1 year post-onset.

  • National Aphasia Association Statement:

    • “If the symptoms of aphasia last longer than 2-3 months after a stroke, a complete recovery is unlikely.”

General Recovery Insights

  • Recovery from aphasia is generally slow, but improvement can occur over years or even decades.

  • Individual recovery varies greatly.

  • Ongoing therapy usually continues after hospital discharge.

  • Acknowledge the personal skills that assist in recovery process.

Three-Prong Approach to Recovery

  1. Spontaneous Recovery (SR): Elements beyond control helping recovery.

  2. Pharmacological Approaches: Use of medication for recovery and prevention.

  3. Effortful Recovery: Involves therapy participation and active involvement.

Neuroplasticity

  • Neuroplasticity Defined:

    • The phenomenon where new neurons can be created, especially notable in the hippocampus.

    • The brain can generate new axons and dendrites.

    • Despite cell death in damaged areas, surrounding regions can adapt and change in function.

Neurochemical Plasticity

  • Brain-Derived Neurotrophic Factor (BDNF):

    • Stored in axons and dendrites.

    • Released during activity.

    • Optimally thrives in enriched environments, including:

    • Cognitive Activity

    • Social Connection and interaction

    • Physical Activity

Time Post Onset (TPO)

  • Time Post Onset (TPO): The duration since a person acquired aphasia.

  • Spontaneous Recovery (SR): Natural healing of the brain post-injury.

  • Patients in earlier stages post-injury tend to have a more positive prognosis than those in chronic stages due to availability of SR.

Stages of Language Recovery

  1. Acute Stage:

    • Occurs within the first few hours and days post-stroke; rapid and frequent improvements.

  2. Subacute Stage:

    • Lasts weeks; relies on neural reorganization.

  3. Chronic Stage:

    • Extends from months to years; involves compensatory reorganization of cognition.

Brain Changes Underlying Recovery

  • Key Mechanisms of Recovery:

    • Reduced swelling: Affected areas regain function post-pressure alleviation.

    • Reperfusion: Restoration of blood flow; surrounding areas improve.

    • Resolution of Diaschisis: Recovery of brain structures dissociated from injury.

    • Neuronal Regeneration: New connections can form near dead cells, yet the dead cells cannot be revived.

    • Long-term Potentiation: Increased synaptic efficiency in surviving neurons compensates for loss.

    • Unmasking: Activation of previously dormant pathways facilitates compensation.

    • Cortical Reorganization: Different brain areas adapt functions previously unassigned to them.

The Myth of the Aphasia Plateau

  • Diagram illustration of recovery:

    • Traditional idea suggests plateau occurs, but true recovery pattern is more varied over time.

  • Key Point: Longitudinal studies often show improvements persisting beyond the typical 1-2 year mark.

Treatment Efficacy Studies

  • Moss & Nicholas (2006):

    • Reviews chronic PWA studies and finds no straightforward correlation between TPO and treatment efficacy.

    • Patients benefit from appropriate treatment irrespective of time post-onset.

Prognostic Factors in Recovery

Lesion Location and Size

  • Difficult to disentangle but crucial.

  • Lesion size is often less critical than lesion location.

  • In Wernicke’s area, size impacts auditory comprehension recovery; poor prognosis if over half is affected.

Etiology

  • Traumatic aphasias typically show more favorable recoveries compared to those resulting from cerebrovascular accidents (CVA).

  • Stroke Types:

    • Hemorrhagic may exhibit better recovery than ischemic strokes, assuming initial survival.

    • Aphasia from Primary Progressive Aphasia (PPA) is expected to deteriorate.

Type of Aphasia

  • Global aphasia often thought to reflect lesser recovery, but this varies based on measurement type (impairment vs. participation).

  • Acute presentation of conduction aphasia positively correlates with recovery; may evolve through syndromic stages (Wernicke’s to Anomic).

Severity of Aphasia

  • Initial Aphasia Severity: Most consistent prognostic indicator; more severe initial speech correlates with worse prognosis.

Age Factors

  • Age itself generally does not significantly impact recovery outcomes but pertains to various health conditions affecting recovery, which worsen with age (e.g., heart disease, diabetes).

Normal Aging and Cognition

  • Typical aging can result in worsened lexical retrieval and cognitive slowing, affecting recovery.

  • Difficulties: Include slower response times, decline in working memory, and challenges in memory sources.

Age and Aphasia Type

  • Age correlates with aphasia type; individuals with Broca's aphasia tend to be younger than those with Wernicke's or other fluent types.

  • Suggests survivability bias: older individuals with significant strokes might not survive complex non-fluent forms.

Cognitive Deficits

  • The presence and severity of other deficits (executive functions, memory, and visuospatial) can affect language recovery, as language function relies on these skills.

Education Levels

  • Direct impacts of education on recovery remain unproven.

  • However, lower socioeconomic status (SES), often associated with lower education, correlates with more severe initial aphasia presentations.

Psychosocial Factors

  • Premorbid personality traits and mental health can significantly impact recovery but lack extensive research.

  • Individuals with anxiety or depression might struggle more with therapy and social communication.

Social Supports

  • Types of Available Social Support:

    • Emotional/Informational: Guidance and feedback.

    • Positive Social Interaction: Participation in enjoyable activities with others.

    • Affectionate Support: Love and emotional backing.

    • Tangible Support: Material assistance.

  • Positive correlations observed with higher self-reported support improving recovery outcomes.

Handedness

  • Individuals who are left-handed but have right-hemisphere dominance for language may recover better.

  • Handedness as a predictor is unreliable prior to recovery; often used to explain exceptional recovery cases retrospectively.

Gender Differences

  • Research by Sharma et al. (2019) indicates men exhibit greater impairment levels, though some earlier studies did not find significant gender differences regarding recovery outcomes.

Speech Therapy Intensity

  • Notable improvements in overall language recovery occur at 20-50 hours of therapy and 2-4 hours per week.

  • Significant comprehension gains at levels of 9+ hours weekly and 4-5 days, while below 20 hours shows no comprehension improvement.

Prognosis Indicators

Good Prognosis Indicators
Historical Context:

  • Non-global aphasia presentation.

  • Short elapsed time post-onset.

  • Absence of lesions in principal language regions.

  • Strong family and social support.

Evaluative Indicators:

  • Behavioral variability observed.

  • Stimulability for improved behaviors.

  • Observable improvements over evaluation period.

  • Initiation of any form of communication.

  • Awareness of deficits.

Poor Prognosis Indicators
Historical Context:

  • Presentation of global aphasia.

  • Prolonged elapsed time post-onset.

  • Lesions impacting core language areas.

  • Lack of social and family support.

  • Additional health complications present.

Evaluative Indicators:

  • Little to no behavioral variability; severe aphasia.

  • Lack of stimulation potential for behavioral changes.

  • No observable improvements during evaluation.

  • Absence of spontaneous communication attempts.

  • Poor awareness of deficits.

Making Prognosis Statements

  • Be specific when discussing prognosis for improvement of particular language functions rather than generalized predictions.

  • This specificity enhances the ability to convey positive potential for recovery.

  • Example Statement:

    • “The prognosis for improvement of spontaneous speech is poor given the lesion size and location and time post-onset, but the prognosis for improvement of functional communication is excellent due to the patient’s motivation, utilization of nonverbal communication strategies during evaluation, and robust family support system.