Evidence-Based Review of Stroke Rehabilitation: 19th Edition

Retrieved September 29

Teasell, R. W., Cotoi, A. I., et al. (2018).

Retrieved September 29, 2022 from http://www.ebrsr.com.

This updated systematic review investigates the effects of pharmacological and non-pharmacological interventions on a variety of stroke symptoms in individuals undergoing stroke rehabilitation. This summary highlights conclusions related to aphasia, dysphagia, perceptual disorders and cognitive disorders within the scope of speech-language pathology.

Canadian Partnership for Stroke Recovery

This systematic review is periodically updated by chapter (module), rather than as a whole document. At the time of writing, we consulted the most current version for each module. We have included this information with each recommendation for your convenience. To check for content published since the time of our writing, please view the authors' <a href="http://www.ebrsr.com/" title="http://www.ebrsr.com/" class="ApplyClass">website</a>.

Up to July 2015

All study designs (not further specified)

1,901

The authors conclude that compensatory memory strategies (e.g., imagery-based, process-oriented strategies) may improve memory outcomes for individuals post stroke (Level 1a Evidence; 2016 Module 12, p. 31) and that "mental imagery may improve relearning of activities of daily living in patients with acute stroke and minimal cognitive deficits" (Level 1b and Level 2 Evidence; 2016 Module 12, p. 31). Further research for this population is warranted.

Individuals with aphasia post stroke who received speech and language therapy from volunteers achieved similar comprehension and communicative ability outcomes compared to those who received therapy from speech-language pathologists (Level 1b and Level 2 Evidence; 2016 Module 14, p. 17).

"There is limited level 1a evidence that group treatment may improve communicative ability but not conversational ability, non-verbal reasoning, verbal expression, auditory comprehension or fluency as compared to individual treatment" (2016 Module 14; p. 18).

<p>The following conclusions were made regarding effects of language therapy in aphasia post stroke:</p> <ul> <li>Language therapy, compared to no treatment, may not improve performance on comprehensive language assessment, comprehension, oral expression, or communicative ability (Level 1a and Level 2 Evidence; 2016 Module 14).&nbsp;</li> <li>Evidence for the effect of language therapy on ability to communicate, compared to a non-aphasia therapy program, is limited and conflicting (Level 1a and Level 2 Evidence; 2016 Module 14).</li> <li>Different types of aphasia intervention, compared to one another, may not be significantly different in improving comprehension, ability to communicate, language or cognitive impairment (Level 2 and Level 4 Evidence; 2016 Module 14).</li> </ul>

"Conflicting level 2 evidence suggests that formal dysphagia therapy may not be beneficial" (2016 Module 15; p. 37).

Cognitive rehabilitation may improve divided attention for individuals post stroke, but may not improve performance on global measures of attention and standardized assessments (Level 1a Evidence; 2016 Module 12, p. 27).

"There is conflicting and limited level 2 evidence in reference to the effect of audio-visual naming training on word retrieval ability when compared to audio only naming training" (2016 Module 14; p. 24).

There is limited Level 1a evidence suggesting that computer-based therapy may improve word retrieval ability on a short-term basis. Language function or word retrieval ability were not affected in the long term (2016 Module 14; p. 24).

<p>Overall, the authors reported it is "unclear whether transcutaneous electrical stimulation improves swallowing function, or reduces the incidence of aspiration pneumonia" (2016 Module 15; p. 46). Conclusions from the review on this topic include:</p> <ul> <li>Conflicting level 1a, level 1b, and level 2 evidence suggests that transcutaneous electrical stimulation, compared to traditional swallowing treatment, "may or may not improve swallowing function" (2016 Module 15; p. 45).</li> <li>Conflicting level 1b and level 2 evidence suggests that electrical stimulation, when compared to traditional swallowing treatment, "may or may not improve the incidence and severity of penetration-aspiration. However, similar evidence suggests no effect of electrical stimulation on the incidence of aspiration pneumonia or nutritional status" (2016 Module 15; p. 45).&nbsp;</li> <li>Electrical stimulation in combination with traditional swallowing treatment, compared to traditional swallowing treatment alone, may reduce incidence of swallowing restrictions (Level 2 Evidence; 2016 Module 15; p. 45).&nbsp;</li> <li>Electrical stimulation, compared to thermal-tactile stimulation, may improve swallowing function and reduce "incidence and severity of penetration-aspiration" (Level 2 Evidence; 2016 Module 15; p. 46).&nbsp;</li> </ul>

Limited level 2 evidence suggests remote assessment and remote treatment for aphasia are as effective as face-to-face delivery (2016 Module 14; p. 26).

Level 1a evidence indicates intensive language therapy may not be effective in improving comprehension, ability to communicate, or performance in cognitive and language tasks compared to standard language therapy. However, there is additional conflicting Level 2 evidence (2016 Module 14, p. 16). Evidence indicates "19.3 hrs of speech therapy program may improve performance on comprehensive language assessments compared to standard therapy (6.9hrs)" (Level 1b Evidence; 2016 Module 14; p. 16).

For individuals with cognitive deficits post stroke, there is mixed evidence that computer-assisted training of attention tasks may improve performance of specific attention (Level 1a and Level 2 Evidence; 2016 Module 12, p. 27). Moderate evidence suggests that "an intensive, computerized training program may result in improvements in both working memory and attention" (Level 1b Evidence; 2016 Module 12, p. 27).

High-intensity swallowing treatment with dietary prescription, compared to lower intensity or usual care, may improve recovery of normal diet and swallow function in patients with post-stroke dysphagia (Level 1b Evidence; 2016 Module 15; p. 37).

Filmed language instruction, in combination with speech therapy, may be as effective as traditional speech therapy alone (Level 1b Evidence; 2016 Module 14; p. 27), and limited Level 5 evidence suggests biological feedback during speech treatment may also be helpful (2016 Module 14; p. 27).

"There is limited level 2 evidence that computer-based aphasia therapy may improve communicative ability and language function when compared to no treatment" (2016 Module 14; p. 24).&nbsp;Computer-based treatment with a reading comprehension focus, compared to a cognitive rehabilitation focus, may improve communication/language impairments (Level 2 Evidence; 2016 Module 14; p. 24).

Limited level 2 evidence suggests constraint-induced aphasia therapy (CIAT) delivered by trained laypersons may be as effective for aphasia as CIAT delivered by experienced therapists (2016 Module 14; p. 31).

Conflicting and limited level 1a evidence suggests constraint-induced aphasia therapy is effective in improving language performance (2016 Module 14; p. 31).

Limited level 2 evidence suggests constraint-induced aphasia therapy (CIAT) and Promoting Aphasics' Communicative Effectiveness (PACE) treatment may be similarly effective in improving confrontational word retrieval (2016 Module 14; p. 31).

Group treatment, individual treatment, and combined individual/group treatment may not differ in improving word retrieval (Level 1b Evidence; 2016 Module 14, p. 18).

There is limited level 2 evidence which suggests that immediate group therapy may be more effective for language impairment than deferred group therapy, but "evidence for the effect on communicative ability is conflicting" (2016 Module 14; p. 18).

Limited level 2 evidence supports intervention by speech-language pathologists for individuals with global aphasia post-stroke (2016 Module 14; p. 41).

There is limited evidence for the use of group treatment to improve memory skills for individuals with cognitive deficits post stroke (Level 2 Evidence; 2016 Module 12, p. 31).

The authors conclude that "attention processing training may improve aspects of visual and auditory attention" (Level 1b Evidence; 2016 Module 12, p. 27). Further research is needed to determine the effects of attention training for individuals with cognitive deficits post stroke.

Level 1a and limited level 2 evidence indicates semantic and phonological cues assist in lexical retrieval. Authors state more studies are needed to determine the effect of combined picture-naming therapy and gesture therapy on word retrieval; at this time there is only conflicting level 1b and limited level 2 evidence (2016 Module 14; p. 40).

There is evidence that supports the use of visual scanning strategies to improve visual neglect post-right hemisphere stroke. The authors conclude that: <ul> <li>Visual scanning training and electrical somatosensory stimulation are more beneficial than visual scanning training in isolation (Level 1b Evidence, 2016 Module 13, p. 22).</li> <li>Computer-based visual scanning training and virtual reality treatment appears to be effective in improving visual perception compared to no treatment or conventional treatment (Level 1b and Level 2 Evidence, 2016 Module 13, p. 19).</li> </ul>

<p>Authors conclude Melodic Intonation Therapy (MIT) may be beneficial; limited evidence suggests it may have similar effects on improvement as standard language treatment.</p> <ul> <li>Level 1b and limited level 2 evidence suggests MIT improves word retrieval or performance on comprehensive language assessments as effectively as standard treatment. Evidence on its improvement of repetition is conflicting.</li> <li>Limited level 2 evidence suggests MIT improves responsive speech, but not repetition (2016 Module 14; p. 29).</li> </ul>

Ultrasonography may provide comparable results to videofluoroscopy for appropriately diagnosing dysphagia (Level 2 Evidence; 2016 Module 15; p. 33). However, the authors suggest further research is needed in using this tool to detect dysphagia and aspiration post stroke (2016 Module 15; p. 33).

Authors state further research is needed investigating the effectiveness of treatment of alexia for individuals with aphasia post-stroke (2016 Module 14; p. 42).

"There is conflicting level 1b and level 2 evidence regarding the effect of intensity and presence of thermal application on the incidence of aspiration and penetration" (2016 Module 15; p. 47); however, evidence indicates "swallowing efficiency is improved, specifically among patients with supranuclear lesions after dry swallow preceded by ice massage of the oral cavity" (Level 1b Evidence; 2016 Module 15; p. 47).

There is evidence that supports the use of gesture training for the treatment of apraxia post-stroke (Level 1b Evidence, 2016 Module 14, p. 57). Training effects may "may be associated with improvements in ideomotor apraxia extending to activities of daily living. These effects may be sustained for at least 2 months following the end of treatment" (2016 Module 14, p. 57).

Evidence suggests "thin fluids may be associated with an increase of total fluid intake; however, it is also associated with an increase in aspiration pneumonia" (Level 2 Evidence; 2016 Module 15; p. 35). Evidence supports that "diets involving thickened liquids [improve] overall swallow safety and [reduce] incidence of aspiration pneumonia versus lower viscosity diets" (Level 1b and Level 2 Evidence; 2016 Module 15; p. 35).

Swallow screening protocols may reduce incidence of pneumonia in patients with dysphagia post stroke, compared to usual care or no screening protocol (Level 2 Evidence; 2016 Module 15; p. 20).&nbsp;With regards to specific dysphagia screening tools, the authors state further research is needed, a variety of tools exist, and that "a single tool with optimal accuracy has yet to be described" (2016 Module 15; p. 25).

"There is an absence of evidence regarding the use of multi-modal interventions following stroke. Based on a single, small study, there is limited evidence that a multi-modal, home-based cognitive rehabilitation program may be beneficial in terms of cognitive function and instrumental activities of daily living" (2016 Executive Summary, p. 19).

<p>Limited evidence exists regarding executive functioning and problem solving treatments post-stroke. The authors reported the following conclusions:</p> <ul> <li>There is limited evidence in support of problem-solving skills training to increase problem-solving skills and executive functioning skills in the context of daily living (Level 1b Evidence, 2016 Module 12, p. 33).</li> <li>There is limited evidence that self-regulation training may improve executive function skills (Level 1b Evidence, 2016 Module 12, p. 33).</li> <li>There is limited evidence that Goal Management Training may improve executive function skills (Level 1b Evidence, 2016 Module 12, p. 33).</li> </ul>

Training conversational partners may improve conversational participation and communication skills for persons with aphasia and their communication partners (Level 1b Evidence; 2016 Module 14, p. 21).

<p>The following conclusions regarding the videofluoroscopic modified barium swallow (VMBS) were presented:</p> <ul> <li>"[VMBS] studies are considered the gold standard for dysphagia/aspiration diagnosis" (2016 Module 15; p. 29).&nbsp;</li> <li>Scintigraphic and videofluoroscopic results can be associated with swallowing function (Level 3 Evidence; 2016 Module 15; p. 29).&nbsp;</li> <li>Scintigraphy shows promise in detecting penetration/aspiration in dysphagia. However, further research is needed (2016 Module 15; p. 29).</li> </ul>

Immediate language therapy may not be more effective than deferred therapy in improving non-verbal reasoning, reading comprehension, or auditory comprehension. Evidence for improving overall communication ability is conflicting (Level 1b and Level 2 Evidence; 2016 Module 14, p. 17).

Use of flexible endoscopic evaluation of swallowing (FEES) may reduce incidence of pneumonia (compared to no assessment)&nbsp;and increase the likelihood of patients' discharging on a standard diet. However, FEES may also be associated with longer period of non-oral feeding and longer length of hospital stay (Level 4 Evidence; 2016 Module 15; p. 31).

The authors state further research is needed regarding the effect of head positioning (e.g., chin down, head turn) on swallow function (2016 Module 15; p. 46).

There was a wide range found in the validity and clinical usefulness of bedside clinical examinations to assess dysphagia secondary to stroke (2016 Module 15; p. 27). Further research is warranted.

Further research is needed on whether pulse oximetry is clinically useful in detecting dysphagia and aspiration post-stroke (2016 Module 15; p. 32).