National Clinical Guideline for Stroke for the United Kingdom and Ireland
Intercollegiate Stroke Working Party. (2023).
London: Royal College of Physicians, Available from https://www.strokeguideline.org/.
This evidence-based guideline provides recommendations for providing care to adults ages 16 years or older who have experienced stroke, transient ischemic attack, or subarachnoid hemorrhage. This guideline updates the 2016 version.
Scottish Intercollegiate Guidelines Network; National Clinical Programme for Stroke, Ireland.
Royal College of Physicians (London; United Kingdom); Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland
<div>Individuals with dysphagia following stroke should be considered for rehabilitation which may include muscle strengthening exercises or neuromuscular electrical stimulation. Behavioral intervention should be based on dysphagia assessment conducted by a speech language pathologist.</div>
<p>A stroke rehabilitation unit should have a single multidisciplinary team including specialists in: medicine, nursing, physical therapy, occupational therapy, speech-language therapy, dietetics, psychology, social work, and orthoptics; "with timely access to rehabilitation medicine, specialist pharmacy, orthotics, specialist seating, assistive technology and information, advice and support (including life after stroke services) for people with stroke and their family/carers" (p. 18).</p>
<p>A hyperacute stroke unit should have speech-language pathology staffing levels at 0.48 whole-time equivalents per 5 beds and acute/rehabilitation stroke units should provide speech-language pathology staffing levels of 0.56 whole-time equivalents per 5 beds.</p>
<p>Multidisciplinary services providing early supported discharge and community stroke rehabilitation should include speech-language pathologists on the core team at a staffing level of 0.4 whole-time equivalents per 100 referrals to a service.</p>
<div>Individuals with tracheostomy and severe dysphagia following stroke should be considered for phrayngeal electrical stimulation to aid in decannulation.</div>
<div>Self-directed rehabilitation should be considered for people with stroke who are able to follow instructions independently or with the support of a caregiver. This may include computerized speech and language programs, in addition to standard rehabilitation, to increase practice.</div>
<div>People with respiratory impairment that are at risk of pneumonia following stroke should be considered for respiratory muscle training using either a threshold resistance trainer or a flow-oriented resistance trainer. Training should be carried out for at least 20 minutes a day, for 3 days a week, for 3 weeks. The relevant clinicians, including speech-language pathologists, should be trained in using the training equipment.</div>
<div>Patients with acute stroke should have swallowing screened within four hours of arrival at the hospital before being given any food, fluid, or medication. Swallow screening should be conducted by a trained professional using a validated tool.<br><br>Until safe swallowing is established, patients with swallowing difficulty should have a comprehensive swallowing assessment completed by a dysphagia specialist within 24 hours of admission.<br><br>People with stroke who require tube feeding, diet modification, or have suspected aspiration should be considered for instrumental assessment of swallowing, which should be received in conjunction with a dysphagia specialist.</div>
<div>For those individuals requiring modified diets, consistency should be in line with internationally agreed upon descriptors such as the International Dysphagia Diet Standardization Initiative. The option to eat and drink normally should be considered with acknowledgement of risks. This decision-making process should be conducted as part of a patient-centered, multidisciplinary team with assessment and steps to minimize risk. People receiving palliative care should not have restrictions on foods that would exacerbate suffering. This may involve a multidisciplinary decision in conjunction with the person with stroke and care partners to allow oral intake despite risks.</div>
<div>When screening cognition following stroke, healthcare providers should take case history from care partners to establish a baseline.<br><br>People with stroke should be screened for cognitive difficulty as soon as they are able, typically within the first few days following stroke onset.<br><br>Those identified by screening to have cognitive impairment following stroke should have further functional and cognitive assessment to determine the nature of their difficulties.<br><br>Community stroke teams should be available for referrals for additional cognitive assessment and management of risk when it is inappropriate for assessment to be conducted in the acute hospital setting. <br><br>Those returning to cognitively demanding roles should have detailed cognitive assessments performed by assessors with appropriate training.</div>
<div>Following stroke, people who appear to have difficulty attending or concentrating should have attentional abilities assessed with standardized measures.</div>
<div>People with stroke who report or exhibit memory difficulty should have memory assessed via standardized measures to establish a profile of impaired and preserved abilities.</div>
<div>People with stroke who fail to initiate, organize, or inhibit behavior should be assessed via standardized assessment for dysexecutive syndrome.</div>
<div>Individuals with stroke that affects the non-dominant cerebral hemisphere, typically the right hemisphere, should be assessed for impaired awareness on the contralateral side as well as problems with spatial awareness using a standardized battery that includes effects on functional tasks.</div>
<div>Individuals with swallowing difficulty following stoke should be considered for compensatory strategies such as texture or sensory modification of foods or postural changes or swallowing maneuvers, to reduce risks of aspiration and choking.</div>
<div>Individuals with stroke should be screened for delirium throughout inpatient stay. Multidisciplinary teams should be aware of delirium. Unexpected changes in cognition should prompt further assessment.</div>
<div>Those with impaired attention should have cognitive demands reduced (e.g., taking planned rests, reducing background distractions); they should have the impairment explained to them, their care partners, and the multidisciplinary team; they should be offered attentional intervention (e.g., time pressure management, attention process training); and they should be given opportunities to practice their activities under supervision.</div>
<div>People with stroke and cognitive difficulty should have impairment explained to them, their care partners, and the multidisciplinary team; be assessed for contributing factors, be trained in approaches to help them encode/store/retrieve new information (e.g., spaced retrieval) or deep encoding of material; be trained in compensatory techniques (e.g., use of reminders or checklists); and receive therapy in an environment similar to their usual one.</div>
<div>People with executive function impairment should have their impairment explained to them, their care partners, and the multidisciplinary team. Care partners and clinicians should be trained in internal and external compensatory techniques and how to give structured feedback.</div>
<div>Those with unilateral impaired awareness after stroke should have the condition explained to them. They should be trained in compensatory measures, be given cues during therapy to draw attention to the impacted side, be offered interventions to reduce the functional impact of reduced awareness (e.g., visual scanning training), and be monitored while eating to ensure they do not miss food on one side of the plate.</div>
<div>People who are discharged with continued swallowing difficulty should be trained in swallowing management and be regularly reassessed.</div>
<div>A speech-language pathologist should assess individuals early after stroke for communication difficulty in order to devise a plan of care and explain implications to the person, care partners, and multidisciplinary team.</div>
<div>People with communication difficulty should be assessed and trained to use assistive technology and be offered communication aids.</div>
<div>People with aphasia after stroke should be given the opportunity to improve language and communication as long at they make meaningful gains, under the direction of a speech-language pathologist. Intensive therapy may be considered from 3 months post-stroke for those able to tolerate it.<br><br>They should be offered access to practice-based digital therapy, and social and participatory activities. Care partners should be trained to improve communication skills and promote autonomy and participation.</div>
<div>People with aphasia post-stroke whose first language is not English should be assessed and given information regarding aphasia in their preferred language. They should also be offered therapy in their preferred language. Referral to services such as interpreters should be made early to facilitate prompt assessment and treatment.</div>
<div>People with unintelligible speech post-stroke should be assessed by a speech-language pathologist to diagnose the condition and educate the person, their care partners, and the multidisciplinary team regarding the nature and implications.</div>
<div>People with post-stroke dysarthria should be trained in techniques to improve speech clarity and be assessed for compensatory and augmentative communication techniques. Communication partners should be trained in how to assist a person with severe dysarthria with their communication.</div>
<div>Individuals with marked difficulty articulating words following stroke should be assessed and treated for apraxia of speech to improve intelligibility. People with severe communication difficulty, but good cognitive-linguistic function, should be assessed and provided alternative and augmentative communication techniques to supplement limited speech.</div>
<div>For individuals with post-stroke aphasia, telepractice should be personalized. Telepractice should be used when it is considered beneficial, but not as an alternative to in-person services. Telepractice services should be monitored by the therapist, and be supplemented with in-person reviews.</div>
