Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Stroke
Winstein, C. J., Stein, J., et al. (2016).
Stroke, 47(6), e98-e169.
This guideline provides recommendations for the rehabilitation of adults recovering from a stroke. The target audience includes all relevant professionals involved in the rehabilitation management of stroke patients, which includes speech-language pathologists and audiologists. Of particular interest to clinicians are the recommendations for the assessment of communication, cognition, swallowing, and hearing. Recommendations for management options are also presented.
American Heart Association/American Stroke Association
American Academy of Physical Medicine and Rehabilitation; American Society of Neurorehabilitation; American Academy of Neurology; American Congress of Rehabilitation Medicine
The data in this guideline are included in other documents which can be found in the Associated Article section below.
<p>"Interventions for motor speech disorders [i.e., dysarthria and apraxia of speech] should be individually tailored and can include behavioral techniques and strategies that target</p>
<ul>
<li>physiological support for speech, including respiration, phonation, articulation, and resonance; and</li>
<li>global aspects of speech production such as loudness, rate, and prosody" (Level B Recommendation, Class I Evidence; p. e125).</li>
</ul>
<div>Swallowing treatment should incorporate the principles of neuroplasticity for adults with stroke-induced dysphagia (Level C Recommendation, Class IIa Evidence).</div>
<div>For individuals with stroke-induced aphasia, computer-based treatment may be included as a supplement to speech and language treatment (Level A Recommendation, Class IIb Evidence).</div>
<div>The benefits of neuromuscular electrical stimulation or pharyngeal electrical stimulation are uncertain. Therefore, this treatment is currently not recommended for adults with stroke-induced dysphagia (Level A Recommendation, Class III Evidence).</div>
<div>For individuals with dysarthria or apraxia of speech secondary to a stroke, "augmentative and alternative communication devices and modalities should be used to supplement speech" (Level C Recommendation, Class I Evidence; p. e125).</div>
<div>"Individuals with stroke should be evaluated for balance, balance confidence, and fall risk" (Level C Recommendation, Class I Evidence; p. e127).</div>
<div>Instrumental evaluation of swallowing is recommended for stroke patients with suspected dysphagia to confirm presence/absence of aspiration, find the physiological reasons for dysphagia, and assist with establishing a treatment plan (Level B Recommendation, Class I Evidence).</div>
<div>Oral hygiene protocols are recommended for patients with dysphagia to reduce the risk of aspiration pneumonia post stroke (Level B Recommendation, Class I Evidence).</div>
<div>For stroke patients with hearing loss, "it is reasonable to use communication strategies such as looking at the patient when speaking" (Level C Recommendation, Class IIa Evidence; p. e136) and "it is reasonable to minimize the level of background noise in the patient's environment" (Level C Recommendation, Class IIa Evidence; p. e136).</div>
<div>For individuals with stroke-induced aphasia, communication partner training should be included as part of treatment (Level B Recommendation, Class I Evidence).</div>
<div>Swallowing assessment is recommended prior to oral intake (Level B Recommendation, Class I Evidence).</div>
<div>Telerehabilitation may increase access to care and "be useful when face-to-face [speech] treatment is impossible or impractical" for adults with apraxia or dysarthria secondary to stroke (Level C Recommendation, Class IIa Evidence; p. e125).</div>
<div>Early dysphagia screening is recommended for adults with acute stroke (Level B Recommendation, Class I Evidence). Dysphagia screening should be completed by a speech-language pathologist or another healthcare professional trained in dysphagia (Level C Recommendation, Class IIa Evidence).</div>
<div>For individuals with dysarthria or apraxia of speech, speech activities "to facilitate social participation and promote psychosocial well-being may be considered" (Level C Recommendation, Class IIb Evidence; p. e125).</div>
<div>For stroke patients with hearing loss, "it is reasonable to use some form of amplification (e.g., hearing aids)" (Level C Recommendation, Class IIa Evidence; p. e136).</div>
<div>For individuals with stroke-induced aphasia, speech and language therapy is recommended (Level A Recommendation, Class I Evidence).</div>
<div>For individuals with dysarthria or apraxia of speech secondary to a stroke, "environmental modifications, including listener education, may be considered to improve communication effectiveness" (Level C Recommendation, Class IIb Evidence; p. e125).</div>
<div>While there are no recommendations for the exact frequency, intensity, timing, format or duration of treatment, the guideline indicates that intensive treatment (Level A Recommendation, IIa Evidence) and group treatment (Level B Recommendation, IIb Evidence) may be warranted for individuals with stroke-induced aphasia.</div>
<div>For patients who may have a hearing loss, "it is reasonable to refer to an audiologist for audiometric testing" (Level C Recommendation, Class IIa Evidence; p. e136).</div>
<div>"Evaluation of stroke patients for sensory impairments, including touch, vision, and hearing, is probably indicated (Level B Recommendation, Class IIb Evidence; p. e118).</div>
<div>Recommendations for the type of instrumental swallowing evaluation (i.e., use of videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, or fiberoptic endoscopic evaluation of swallowing with sensory testing) should be determined based on availability and other patient considerations (Level C Recommendation, Class IIb Evidence).</div>
<div>Behavioral swallowing interventions are recommended as a component of treatment for adults with stroke-induced dysphagia (Level A Recommendation, Class IIb Evidence).</div>
