Clinical Practice Guideline on Stroke Rehabilitation

Philippine Academy of Rehabilitation Medicine. (2017).

Manila (Philippines): Philippine Academy of Rehabilitation Medicine, (2nd Edition), 1-624.

This updated clinical practice guideline from the Philippine Academy of Rehabilitation Medicine provides recommendations regarding the assessment, management, and rehabilitation of patients suffering from stroke. This summary highlights recommendations within the scope of speech-language pathology (e.g., aphasia, cognition, dysphagia, telepractice).

Philippine Academy of Rehabilitation Medicine

<div>Stroke patients with dysarthria should receive individualized speech motor skill interventions (PARM Suggests). Appropriate treatments may include:</div> <ul> <li>augmentative and alternative communication devices (PARM Suggests);</li> <li>behavioral treatments for physiological supports of speech (e.g., respiration, phonation, articulation, resonance) (PARM Suggests);</li> <li>biofeedback (PARM Suggests);</li> <li>counseling and behavioral support groups to improve participation and psychosocial well-being (PARM Suggests);</li> <li>environmental modifications (PARM Suggests);</li> <li>listener education (PARM Suggests);</li> <li>oral musculature exercises (PARM Suggests);&nbsp;</li> <li>speech production strategies such as increasing loudness, decreasing rate, over articulating, or gesturing (PARM Suggests); and/or</li> <li>voice amplification (PARM Suggests).</li> </ul>

<div>Stroke patients with dysphagia should be offered swallowing therapy with regular reassessment as needed (PARM Strongly Endorses). Patients should receive high intensity swallowing therapy and dietary prescription (PARM Endorses) with an individualized dysphagia and specialized dietary management plan (PARM Suggests). Dysphagia treatments, some of which may fall outside scope of speech-language pathology practice, may include:</div> <ul> <li>behavioral interventions (PARM Recommends);</li> <li>compensatory techniques (e.g., postures and maneuvers) (PARM Suggests);</li> <li>dietary modifications (e.g., thickened liquids) (PARM Recommends);</li> <li>electrical stimulation (PARM Recommends);</li> <li>encouragement of patient self-feeding when capable and with use of precautions (PARM Endorses);</li> <li>enteral feeding [e.g., nasogastric tube feeding for the first month post-stroke, percutaneous endoscopic gastrostomy (PEG) for 4 weeks or longer] for patients who cannot tolerate oral food and liquid (PARM Recommends);</li> <li>incorporating principles of neuroplasticity into dysphagia rehabilitation (PARM Recommends);</li> <li>low-risk feeding strategies (e.g., eat while sitting, minimize distractions) (PARM Suggests);</li> <li>nutritional supplements for malnourished patients or those at risk of malnourishment (PARM Suggests);</li> <li>oral hygiene protocols (PARM Strongly Endorses);</li> <li>restorative strategies (e.g., shaker head lifting exercise) (PARM Suggests);</li> <li>suprahyoid muscle-strengthening exercise (PARM Endorses); and/or</li> <li>thermo-tactile stimulation (PARM Recommends).</li> </ul>

<div>Stroke patients with apraxia should receive an individualized speech motor skill interventions for dyspraxia (PARM Suggests). Appropriate treatments may include:</div> <ul> <li>articulatory placement cueing (PARM Suggests);</li> <li>augmentative and alternative communication modalities (e.g., gestures, speech-generating devices) (PARM Suggests);</li> <li>behavioral techniques and strategies (PARM Endorses);</li> <li>compensatory strategies (PARM Recommends);</li> <li>feedback on performance and accuracy (PARM Suggests);</li> <li>integral stimulation approach (PARM Suggests);</li> <li>modelling (PARM Suggests);</li> <li>motor learning principles (PARM Suggests);</li> <li>physiological supports (e.g., respiration, phonation, articulation, resonance) (PARM Endorses);</li> <li>PROMPT therapy (PARM Suggests); and/or</li> <li>speech production strategies for aspects like loudness, rate, and prosody (PARM Endorses).</li> </ul>

<div>Stroke patients should undergo an initial assessment of nutritional risk, including their ability to eat independently, within the first 48 hours. Regular nutritional re-assessment with periodic record of their food consumption and weight should occur throughout the patient&rsquo;s recovery (PARM Suggests). On-going nutritional status should include biochemical measures (e.g., impaired glucose metabolism), swallowing status, eating assessment, and nutritional intake (PARM Suggests).</div>

<div>Stroke patients should be treated for communication and/or cognitive disorders including right hemisphere brain damage, neglect, attention, memory, awareness, and other executive function disorders. Treatments and compensatory strategies should be individualized to the patient's deficits and needs (PARM Endorses). A patient-centered approach should be considered for the resumption of daily activities and return to work (PARM Suggests). As appropriate, interventions may include:</div> <ul> <li>attention training (PARM Endorses);</li> <li>compensatory strategies for memory, attention, language, praxis, and executive functioning (PARM Endorses);</li> <li>computer-based, direct remediation cognitive skill training for attention, working memory, and/or language impairments (PARM Strongly Endorses);</li> <li>education for patients and their caregivers on adapting to new roles, on participating in goal setting, and on self-advocacy and self-management skills (e.g., action planning, problem-solving behaviors) (PARM Recommends);</li> <li>environmental enrichments to improve engagement (PARM Recommends);</li> <li>family education regarding communication techniques (PARM Suggests);</li> <li>memory training strategies (e.g., errorless learning, global processing, semantic framework construction) (PARM Endorses);</li> <li>virtual reality training for verbal, visual, and spatial cognition (PARM Endorses); and/or</li> <li>vocational rehabilitation services including advice on benefits, employment, and referral to social work (PARM Recommends).</li> </ul>

<div>Stroke patients considered high risk for cognitive impairment should undergo periodic assessment of cognition, perception, and function across the care continuum. Appropriate times for assessment may include during an acute care stay, during rehabilitation, and after discharge (PARM Suggests).</div>

<div>Rehabilitation for stroke patients is recommended to take place in either hospitals, center-based facilities, or community-based rehabilitation settings depending on the availability of services and personnel and the patient's needs. These program settings are equally effective in achieving modest gains in activities of daily living after inpatient rehabilitation (PARM Strongly Endorses). Treatment programs may include the following:</div> <ul> <li><span style="color: #333333;">Stroke patients with aphasia should participate in conversation groups (PARM Suggests) or outpatient and community-based group therapy to improve communication, social networks, and community access (PARM Recommends). </span><span style="color: #333333;">Group therapy is not recommended to address writing goals (PARM Does Not Recommend). </span></li> <li><span style="color: #333333;">For patients with mild to moderate disability, home-based care or facility-based outpatient care should be considered (PARM Endorses) and should include community-based and coordinated interprofessional rehabilitation care (PARM Strongly Endorses). </span></li> <li><span style="color: #333333;">The rehabilitation team should determine the optimal environment for the patient's care based on the severity of their impairment, rehabilitation needs, availability of family/social support, the individual&rsquo;s goals and preferences, and availability of community resources (PARM Suggests). </span></li> <li><span style="color: #333333;">Home-based support and care management is not recommended for improving social activity, mood, quality of life, and/or physical independence (PARM Does Not Endorse).</span></li> </ul>

<div>When conducting cognitive and communication assessments, clinicians should use standardized, valid, and reliable test procedures to document the presence and nature of any disorders (PARM Recommends). The Montreal Cognitive Assessment screening tool is recommended for periodic assessment of cognitive domains including level of consciousness, attention, orientation, memory, language, visuospatial/perceptual function, praxis, and executive functions (PARM Recommends).</div>

<div>Stroke patients with aphasia should receive at least two hours of speech therapy per week (PARM Recommends). A speech therapy program should be designed for 19.3 hours (PARM Endorses). An intensive language therapy program is not recommended over standard language therapy (PARM Does Not Recommend). Intensity, distribution, and/or duration of speech therapy should be provided as tolerated and feasible for the patient with aphasia (PARM Endorses). Patients should continue aphasia therapy for more than 6 months to address chronic deficits (PARM Recommends).</div>

<div>All stroke patients should be screened for dysphagia before initiation of oral intake (PARM Strongly Endorses). Patients who are not alert should be screened when clinically appropriate (PARM Suggests). Patients with dysphagia should undergo a swallow screen to reduce incidence of pneumonia (PARM Endorses). A water swallow test is recommended as part of the screening for aspiration risk (PARM Strongly Endorses). Gag reflex is not recommended as a screening tool for dysphagia (PARM Does Not Endorse). Typical swallow screening procedure should include observation of the patient&rsquo;s consciousness level, the degree of postural control, oral hygiene, and control of oral secretions (PARM Recommends). For acute stroke patients, instrumental testing of swallowing is not recommended (PARM Does Not Endorse).</div>

<div>Stroke patients should be referred for rehabilitation as early as possible once medically stable, preferably within 24-hours of the onset of stroke (PARM Strongly Endorses). A structured rehabilitation program that provides as much practice as possible, such as attendance at a day program, should be established for the first six months after stroke onset (PARM Recommends). After discharge, rehabilitation should continue at either hospital, center-based, or community-based rehabilitation facilities, depending on the individual's needs, throughout the first year after stroke at a frequency appropriate for the needs of the patient (PARM Strongly Endorses). Stroke patients should resume vocational interests when possible, and a gradual resumption of work should be considered when fatigue is a concern for the patient (PARM Suggests).</div>

<div>Stroke patients with swallowing problems should be assessed by a speech-language pathologist (PARM Strongly Endorses). Patients who fail their swallow screen should be referred to a speech-language pathologist for comprehensive assessment (PARM Suggests).</div>

<div>Assessment of dysphagia for stroke patients may include:</div> <ul> <li>cervical auscultation (PARM Suggests);</li> <li>instrumental assessment [e.g., videofluoroscopic modified barium swallow study (VMBS), flexible endoscopic examination of swallow (FEES)] (PARM Endorses);</li> <li>pulse oximetry to determine oxygen saturation (PARM Suggests); and/or</li> <li>standardized clinical bedside assessment by a skilled dysphagia professional (PARM Endorses).</li> </ul> <div>For stroke patients, instrumental dysphagia assessment should be used in cases when the patient has failed the swallow screening test (PARM Endorses) or when a patient is suspected of aspiration to verify aspiration presence, to determine physiological reasons for dysphagia, and to guide the treatment plan (PARM Recommends). VMBS or FEES may be used (PARM Recommends) as valid methods for assessing dysphagia (PARM Endorses). VMBS and FEES should use established standard criteria for the interpretation of results (PARM Recommends). VMBS should be used to guide management decisions for dysphagia patients (PARM Recommends), while FEES results can be used to reduce pneumonia and improve dysphagia recovery (PARM Suggests).</div>

<div>Stroke patients in outpatient stroke rehabilitation should be referred to an organized rehabilitation team (e.g., physical therapist, occupational therapist, and speech-language pathologist) (PARM Strongly Endorses). This should include the following:</div> <ul> <li><span style="color: #333333;">Patients with cognitive impairment should be managed by a multidisciplinary team with additional healthcare professionals such as a neuropsychologist, social worker, etc. (PARM Suggests). </span></li> <li><span style="color: #333333;">The rehabilitation team, which also includes the patient and their caregiver(s), should assess medical and functional status to determine appropriate rehabilitation services and setting (PARM Suggests). </span></li> <li><span style="color: #333333;">Patients with suspected communication deficits, including aphasia, should be referred to a speech-language pathologist to assess, treat, and manage communication abilities in listening, speaking, reading, writing, gesturing, assistive technology use, pragmatics, and conversation (PARM Recommends). </span></li> <li><span style="color: #333333;">All healthcare providers across the continuum of care should be trained on the impact of aphasia and on appropriate methods to support communication (PARM Recommends).</span></li> </ul>

<div>Caregivers of stroke survivors should be encouraged to attend therapy sessions to receive education, to provide support to the survivor, and to promote the survivor&rsquo;s self-care (PARM Recommends). For stroke patients with aphasia, family members and caregivers should be engaged in services beginning at initial screening and remaining involved through the duration of intervention services (PARM Suggests). Stroke patients and their caregivers should routinely receive information, education, and counselling (PARM Strongly Endorses). They should receive information on local resources and receive formal or informal referrals to community resource contacts (PARM Suggests). People with stroke should undergo regular and ongoing monitoring and follow-up of their recovery and functional outcomes with their caregivers and healthcare providers (PARM Recommends). Individual psychosocial and support needs should be reviewed on a regular basis (PARM Endorses).</div>

<div>For stroke patients, intensity of rehabilitation should be increased according to the individual&rsquo;s tolerance and the benefits on functional outcome (PARM Strongly Endorses). Patients should receive therapy on an as intensive schedule as they are able to tolerate in order to adapt, recover, and/or re-establish premorbid or optimal level of functioning (PARM Endorses). While schedules should be modified to match individual needs and goals, outpatient therapy is recommended for a range of 45 minutes to 3 hours per day, 3 to 5 days per week (PARM Endorses). Stroke patients with chronic motor speech disorders should continue speech therapy with the amount, distribution, frequency, timing, and type of treatment based on the individual&rsquo;s needs (PARM Endorses).</div>

<div>Post-stroke patients should be assessed annually using appropriate evaluation instruments (PARM Endorses) for balance and fall risk including medical, functional, cognitive, and environmental factors (PARM Recommends).</div>

<div>Stroke patients with aphasia should receive an individualized combination of intensive language and communication therapy (PARM Recommends). Appropriate treatments may include:</div> <ul> <li>augmentative and alternative communication modalities (e.g., drawing, gestures, speech-generating devices, writing) (PARM Suggests);</li> <li>communication partner training (PARM Suggests);</li> <li>computer-based programs and assistive technology and devices (e.g., iPads, tablets) to supplement treatment (PARM Recommends);</li> <li>constraint-induced language therapy (PARM Recommends);</li> <li>conversation techniques (PARM Suggests), including supportive conversation (PARM Endorses);</li> <li>education on health, aphasia, and social or community supports written in an accessible, aphasia-friendly format (PARM Suggests);</li> <li>family education and training in supported communication (PARM Suggests); and/or</li> <li>language interventions for phonological and semantic deficits, sentence level processing, reading, and writing derived from cognitive neuropsychology (PARM Suggests).</li> </ul>

<div>Stroke patients, particularly those who live in rural settings, should use alternative methods of communication and support when appropriate (PARM Recommends). Stroke patients with aphasia should receive services via telepractice or telerehabilitation when face-to-face treatment is impossible or impractical (PARM Suggests).</div>

<div>All stroke patients should be screened for communication deficits using valid and reliable screening tools (PARM recommends). Patients should be screened early and throughout the rehabilitation goal setting and planning process for their individual needs and to resume work (PARM recommends).</div>

<div>Stroke patients with suspected communication difficulties, including aphasia, apraxia, and right hemisphere disorder, should receive formal, comprehensive assessment by a specialist (e.g., speech-language pathologist) (PARM Suggests). This should include the following:</div> <ul> <li><span style="color: #333333;">Patients should undergo comprehensive cognitive-communication assessment of all domains (e.g., arousal, attention, orientation, memory, language, executive function) to determine the presence of cognitive or communication disorders (PARM Recommends).</span></li> <li><span style="color: #333333;">Aphasia assessment should include evaluation of motor speech characteristics such as acoustic, auditory-perceptual, and physiological measures of respiration, phonation, resonance, articulation, prosody, and speech intelligibility (PARM Recommends).</span></li> <li><span style="color: #333333;">Stroke patients with right-hemisphere disorders should be assessed for higher-level language and pragmatic abilities across a variety of communication modalities (PARM Suggests). </span></li> <li><span style="color: #333333;">Apraxic patients with unclear or unintelligible speech should be assessed to determine the nature and cause of speech impairment (PARM Suggests). </span></li> <li><span style="color: #333333;">For individuals demonstrating communication disorder, cognitive assessment should either directly or indirectly involve a speech-language pathologist (PARM Recommends). </span></li> <li><span style="color: #333333;">A cognitive assessment should be included as a part of vocational planning (PARM Suggests).</span></li> </ul>