Measuring motivation in people with aphasia: Conceptual foundation and item development

About This Grant

Significance to the VA: Veterans experience strokes more frequently than non-Veterans. One of the most debilitating consequences of a stroke is aphasia, a chronic language disorder that affects one third of stroke survivors. While individuals experience a degree of spontaneous recovery within the first 6-12 months post- stroke, most individuals do not fully recover. Continued neuroplastic change to the language system is conferred via long-term behavioral speech-language treatment which is most effective at high doses. Unfortunately, Veterans receive considerably less treatment than best-practice guidelines. Motivation is likely a major contributor to this gap in clinical care. In fact, the VA Clinical Practice Guidelines for Management of Stroke Rehabilitation cite motivation as a barrier to post-stroke rehabilitation and recommend that clinicians assess motivation. However, there are no motivation-based measures with validity evidence in the context of aphasia rehabilitation, creating a critical gap in clinicians' ability to assess and ultimately intervene upon motivation to optimize the amount of treatment Veterans with aphasia receive. Innovation and Impact: This proposal aims to address this gap by modifying an existing measurement tool that, with appropriate adaptations, can identify causes of suboptimal motivation in the context of aphasia rehabilitation. The measure is grounded in self-determination theory, a well-studied theory of motivation that finds that optimal motivations (described as “autonomous”) lead to improvements in health behavior and well- being, and bolster cognitive functions associated with aphasia treatment response. Autonomous motivations are driven by contexts that support three basic psychological needs (BPNs). Measures of BPNs can identify underlying causes of suboptimal motivation and guide interventions that improve motivation – a critical variable that can increase the dosage of treatment and enhance cognitive skills key to treatment response. Specific Aims and Methodology: This proposal is guided by state-of-the-art guidelines for measure development. In Aim 1, speech pathologists and researchers (n = 30) will be presented with the unmodified scale via survey and identify irrelevant or missing items. An expert panel will modify or develop items using survey data. In Aim 2, Veterans with aphasia (n = 7-10) will be presented with the scale modified in Aim 1. Via cognitive interviewing, Veterans will identify items they find difficult to understand, irrelevant, or missing. An expert panel will modify or develop items using cognitive interview data. In Aim 3, Veterans with aphasia (n = 25) will complete the modified scale to generate validity evidence that can support its use in future research. Path to Translation/Implementation: This proposal constitutes the initial steps of a productive and programmatic line of research evaluating the effect of BPN-focused motivational interventions on aphasia treatment outcomes in a single-subject investigation (CDA-2) and large-scale efficacy research (MR Award). This work will enable clinicians to assess motivation as advised by VA Clinical Practice Guidelines. Existing frameworks of rehabilitation (e.g., the Rehabilitation Treatment Specification System) can aid researchers in using the scale to identify treatment ingredients that optimize motivation, a variable central to outcomes. Immediate and Long-term Career Goals: The applicant is a speech pathologist and an advanced fellow in geriatrics in the Geriatrics Research, Education, and Clinical Center at VAPHS, with experience in aphasia rehabilitation and research. During the CDA-1, mentorship and structured training in measurement theory, qualitative research, motivational science, and professional development will support the completion of the proposed CDA-1 and the applicant's career goals to become an independent VA clinician-scientist supported by VA Merit Review and NIH/NIDCD award mechanisms. The applicant's long-term research program will (1) identify neurocognitive and psychological mechanisms underlying aphasia recovery and (2) determine how treatment ingredients can be modified to maximize aphasia treatment outcomes at the individual level.