Clinical Guidelines for Stroke Management

Stroke Foundation. (2023).

Melbourne (Australia): Stroke Foundation, Retrieved September 18, 2023 from https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management.

This living guideline is an update of the 2017 National Stroke Foundation guideline. It provides recommendations for the assessment and management of stroke and transient ischemic attack in adults. Recommendations are intended to help healthcare professionals provide increased quality of stroke care. Management options within the scope of speech-language pathology and audiology are included within this article summary.

Stroke Foundation (Australia)

Australian and New Zealand Society for Geriatric Medicine; Australian and New Zealand Society for Vascular Surgery; Australian College of Nursing; Australian Physiotherapy Association; Occupational Therapy Australia; Society of Hospital Pharmacists of Australia; Speech Pathology Australia; Stroke Society of Australasia; Royal Australian and New Zealand College of Psychiatrists; Royal Australasian College of Physicians; Australasian Faculty of Rehabilitation Medicine; Continence Foundation of Australia; Dietitians Association of Australia

This guideline is periodically updated by chapter, rather than as a whole document. At the time of writing, we consulted the most current version for each chapter. To check for content published since the time of our writing, please view the authors' <a href="https://informme.org.au/en/Guidelines/Living-guidelines-for-stroke-management" title="https://informme.org.au/en/Guidelines/Living-guidelines-for-stroke-management" class="ApplyClass">website</a>.

"All stroke patients should be admitted to hospital and be treated in a stroke unit with an interdisciplinary team" (Strong Recommendation; Chapter 3, v10.7 2023, p. 4).

"Every stroke patient should have their rehabilitation needs assessed within 24–48 hours of admission to the stroke unit by members of the interdisciplinary team, using an appropriate process or tool," and all patients identified as having rehabilitation needs should be referred to a rehabilitation service (Practice Point; Chapter 3, v10.7 2023, p. 4). The needs or lack of needs should be documented by rehabilitation service providers alongside information about whether "appropriate rehabilitation services are available to meet these needs" (Practice Point; Chapter 3, v10.7 2023, p. 4).

For individuals with stroke-associated dysphagia, non-invasive brain stimulation and neuromuscular electrical stimulation (NMES) should not be used in routine practice other than within a research framework. NMES intervention, when given in the context of a research study, should only be delivered by clinicians trained and experienced in delivering this intervention. Pharyngeal electrical stimulation is not recommended for routine use (Weak Recommendation Against; Chapter 3, v10.7 2023 p. 7).

Swallow screening should be completed "within four hours of arrival at hospital and before being given any oral food, fluid or medication" (Practice Statement; Chapter 3, v10.7 2023, p. 6). "Until a safe swallowing method is established for oral intake, patients with dysphagia should have their nutrition and hydration assessed and managed with early consideration of alternative non-oral routes" (Practice Statement; Chapter 3, v10.7 2023, p. 7).

"Patients with dysphagia on texture-modified diets and/or fluids should have their intake and tolerance to the modified diet monitored regularly due to the increased risk of malnutrition and dehydration" (Practice Statement; Chapter 3, v10.7 2023, p. 7). Any patients with persistent weight loss, dehydration, and/or recurrent chest infection following stroke should be reviewed urgently (Practice Statement; Chapter 3, v10.5 2023 p. 7).

Clinicians may provide interventions to promote adherence with medication regimens to all patients with stroke. These interventions may include combinations of the following elements: <ul> <li>reminders, telephone follow-up, or dose administration aids; </li> <li>use of self-monitoring, reinforcement, counselling, motivational interviewing, family therapy, or supportive care; </li> <li>development of self-management skills; </li> <li>"modification of dysfunctional beliefs about medication"; and </li> <li>information and education regarding medication in the hospital and in the community (Weak Recommendation; Chapter 4, v9 2023; p. 4). </li> </ul>

The following recommendations were made regarding the commencement and timing of out-of-bed activities for patients following stroke: <ul> <li>Intensive out-of-bed activities are not recommended within 24 hours of stroke onset (Strong Recommendation Against; Chapter 5, v10 2022).</li> <li>All stroke patients should begin participating in out-of-bed activity within 48 hours of stroke onset unless contraindicated (Strong Recommendation; Chapter 5, v10 2022).</li> <li>"For patients with mild and moderate stroke, frequent, short sessions of out-of-bed activity should be provided, but the optimal timing within the 48-hour post-stroke time period is unclear" (Weak Recommendation; Chapter 5, v10 2022, p. 5).</li> </ul>

Following stroke, patients should be encouraged actively practice therapy tasks outside of scheduled sessions. This may include: <ul> <li>"self-directed, independent practice; [or] </li> <li>semi-supervised and assisted practice involving family/friends, as appropriate" (Practice Statement; Chapter 5, v10 2022, p. 5).</li> </ul>

If adequate and appropriate, coordinated home-based stroke services are available, patients with mild to moderate stroke may be offered early supported discharge services (Strong Recommendation; Chapter 5, v10 2022). "Home-based rehabilitation may be considered as a preferred model for delivering rehabilitation in the community. Where home rehabilitation is unavailable, stroke patients requiring rehabilitation should receive [center]-based care" (Weak Recommendation; Chapter 5, v10 2022, p. 6).

Throughout the care process, health professionals should "initiate the process of setting goals, and involve stroke survivors and their families and [care partners]. Goals for recovery should be client-[centered], clearly communicated and documented so that both the stroke survivor (and their families/[care partners]) and other members of the rehabilitation team are aware of goals set" (Strong Recommendation; Chapter 5, v10 2022, p. 6). "Goals should be set in collaboration with the stroke survivor and their family/[care partners] (unless they choose not to participate) and should be well-defined, specific and challenging. They should be reviewed and updated regularly" (Strong Recommendation; Chapter 5, v10 2022, p. 6).

The following recommedations were made regarding screening of patient status-post stroke: <ul> <li>All patients should be screened for cognitive communication deficits following stroke. Screening should be conducted using a tool that is valid and reliable (Practice Statement; Chapter 5, v10 2022). </li> <li>Any patients with "suspected communication difficulties should receive formal, comprehensive assessment by a specialist clinician to detemine the nature and type of the communication impairment" (Practice Statement; Chapter 5, v10 2022, p. 11). </li> <li>Any patient suspected as having cognitive deficits "should be referred for comprehensive clinical neuropsychological investigations" (Practice Statement; Chapter 5, v10 2022, p. 14).</li> </ul>

Healthcare professionals and volunteers working with people with aphasia following stroke should receive communication partner training (Strong Recommendation; Chapter 5, v10 2022). Communication partner training may also be provided to the patient's care partners or family members (Weak Recommendation; Chapter 5, v10 2022).

For patients with aphasia, clinicians should: <ul> <li>"document the provisional diagnosis, explain and discuss the nature of the impairment with the patient, family/[care partners] and treating team, and discuss and teach strategies or techniques which may enhance communication; </li> <li>identify goals for therapy, and develop and initiate a tailored intervention plan in collaboration with the patient and family/[care partner]; </li> <li>reassess the goals and plans at appropriate intervals over time; [and] </li> <li>use alternative means of communication (such as gesture, drawing, writing, use of augmentative and alternative communication devices) as appropriate" (Practice Statement; Chapter 5, v10 2022, p. 12).</li> </ul>

Patients with chronic aphasia following stroke should be monitored for mood changes and/or disturbances. The impact of aphasia on functional activities, participation, quality of life, relationships, vocation, and leisure, should be assessed and addressed early post-onset. For individuals with chronic aphasia, these impacts should be addressed and assessed over time (Practice Statement; Chapter 5, v10 2022, p. 13).

"Telehealth services may be used as an alternative approach to delivering rehabilitation, especially for patients who cannot access specialist rehabilitation in the community. It may also be used as an adjunct to in-person therapy. Delivering of specific interventions via telehealth should only be considered for those that have demonstrated benefits" (Weak Recommendation; Chapter 5, v10 2022, p. 16).

The following is recommended for post-stroke fatigue: <ul> <li>Providers should coordinate therapy to be provided during periods of the day in which the patient is most alert.</li> <li>Patients and their families and/or care partners should be provided with information, education, and strategies regarding fatigue management. </li> <li>Providers should consider potential modifying factors of fatigue. Patients should be screening for sleep-related breathing disorders and depression and should be educated to avoid the use of sedating drugs or alcohol. </li> <li>Despite limited evidence regarding these treatments, possible interventions may include cognitive behavioral therapy, exercise, and improving sleep hygiene (Practice Statement; Chapter 6, v10.3 2023 p. 7)</li> </ul>

Behavioural changes after stroke can impact a person’s ability to engage in meaningful activities and their quality of life (Practice Statement; Chapter 6, v10.3 2023, p. 11). The impact of behavioural changes on relationships, employment and leisure should be assessed and addressed across the lifespan. Following stroke, patients and their families and care partners "should be given access to individually tailored interventions for personality and [behavioral] changes, [which] may include positive [behavior] support programs, anger-management therapy and rehabilitation training and support in management of complex and challenging [behavior]" (Practice Statement; Chapter 6, v10.3 2023, p. 11).

Stroke education for patients and their families or care partners should be provided throughout different stages of the recovery process and be tailored to meet the linguistic and communication needs of each individual. Providers should use approaches and materials that encourage active engagement and allow opportunities for follow-up, clarification, and reinforcement (Strong Recommendation; Chapter 7, v5.8 2022, p. 4).

Following stroke, patients and their families or care partners should be given the opportunity to identify and discuss their post-discharge needs with relevant members of the interdisciplinary team. All necessary support services, treatments, and equipment should be organized prior to discharge. A post-discharge care plan should be developed in collaboration with the patient and their family or care partners including "relevant community services, self-management strategies (i.e., information on medications and compliance advice, goals and therapy to continue at home), stroke support services, any further rehabilitation or outpatient appointments, and an appropriate contact number for any post-discharge queries" (Practice Statement; Chapter 7, v5.8 2022, p. 5).

The following is recommended for return to driving following stroke or transient ischemic attack (TIA): <ul> <li>Patients who were previously driving should be asked if they wish to resume driving.</li> <li>Patients wishing to resume driving should be provided with information regarding the potential impacts of their impairments on driving and state-specific process and requirements for returning to driving.</li> <li>Patients should be screened and/or assessed for any ongoing neurological deficits that may influence driving safety, and these assessment findings should be documented. </li> <li>For individuals with no history of driving, medical and clinical team members should discuss the feasibility of driving and provide advice for future steps that are in-line with state guidelines.</li> <li>Facilities should develop an appropriate site-specific process for determination of capacity for driving that are in-line with local legal requirements and resources. All assessment results and advice communicated to the patient and their family or care partner should be relayed to the general practitioner.</li> <li>Patients "should refrain from recommencing driving until both the mandated period of non-driving has elapsed and stroke deficits precluding safe driving (if present) have resolved, as confirmed by their treating doctors (in conjunction with other non-medical clinician/s). Minimum non-driving periods determined by the relevant national [or state] standards must be followed"</li> <li>"If after the minimum exclusion period the treating clinician is uncertain whether persisting motor, sensory or cognitive changes preclude safe driving, an occupational therapy specialist driving assessment should occur."</li> <li>"Patients "should be screened/assessed for any ongoing neurological deficits that could influence driving safely. Visual, cognitive, physical and behavioural assessment findings should be documented." (Practice Statement; Chapter 8, v7.2 2023, p. 5) </li> </ul>

Following stroke, all patients should be asked about their employment and volunteer responsibilities prior to their stroke, and if they wish to return to work. Those who wish to return to work should be provided with assessment "to establish abilities relative to work demands. In addition, assistance to resume or take up work including worksite visits and workplace interventions, or referral to a supported employment service should be offered" (Weak Recommendation; Chapter 8, v7.2 2023, p. 6).

Following stroke, patients and their families or care partners should be given information regarding the benefits and availability of local stroke support groups as well as any additional sources of peer support. This should be given prior to hospital discharge and in the community (Weak Recommendation; Chapter 8, v.7.2 2023, pp. 6-7).

Individuals with stroke-associated executive functioning impairment should receive information in ways that consider their specific deficits (Practice Statement; Chapter 5, v10 2022).

Following stroke, individuals with unilateral neglect should be provided a clear explanation of their deficits, be taught compensatory strategies to reduce the impact of neglect on functional activities. They should be given cues to draw attention to the affected side during therapy procedures and be "monitored to ensure that they do not eat too little through missing food on one side of the plate" (Practice Statement; Chapter 5, v10 2022, p. 16).

Clinicians may provide meta-cognitive strategies and cognitive training to individuals with stroke-associated cognitive impairment (Weak Recommendation; Chapter 5, v10 2022).

Individuals with dysarthria after stroke may receive individually tailored interventions, which may include: <ul> <li>speech production tasks that target connected speech; and </li> <li>strategies to reduce speaking rate, emphasize articulatory placement, or increase loudness (Weak Recommendation; Chapter 5, v10 2022).</li> </ul>

The following is recommended regarding aphasia therapy status post stroke: <ul> <li>Stroke survivors with aphasia should receive speech and language therapy to improve functional communication, reading comprehension, auditory comprehension, expressive language, and written language (Strong Recommendation; Chapter 5, v10 2022). </li> <li>"Early aphasia therapy, starting within the first 4 weeks post stroke, should be provided to maximize language recovery" (Strong Recommendation; Chapter 5, v10 2022, p. 11).</li> <li>"In the acute phase (up to six weeks post stroke onset), language therapy sessions (direct time on task) ranging between 30-45 minutes, two-three days per week may be provided from stroke onset to week 6 post stroke, with additional therapy sessions during this acute phase being unlikely to yield any further benefit to language recovery" (Weak Recommendation; Chapter 5, v10 2022, p. 11).</li> <li>In the chronic phase (greater than 6 month post onset), intensive, therapist-led aphasia therapy (at least 10 hours/week; individual or group) for 3 weeks in combination with at least 5 hours/week of self-managed training may be used to improve aphasia (Weak Recommendation; Chapter 5, v10 2022).</li> </ul>

For patients with confirmed attentional deficits following stroke, cognitive rehabilitation may be used. Exercise training and leisure activities may additionally be provided (Weak Recommendation; Chapter 5, v10 2022).

"Relevant members of the interdisciplinary team should provide specific and tailored training for [care partners]/family before the stroke survivor is discharged home. This training should include, as necessary, personal care techniques, communication strategies, physical handling techniques, information about ongoing prevention and other specific stroke-related problems, safe swallowing and appropriate dietary modifications, and management of [behaviors] and psychosocial issues." (Weak Recommendation; Chapter 7, v5.8 2022, p. 5).

"Environmental barriers facing people with aphasia should be addressed through training communication partners, raising awareness of and educating about aphasia to reduce negative attitudes, and promoting access and inclusion by providing aphasia-friendly formats or other environmental adaptations. People with aphasia from culturally and linguistically diverse backgrounds may need special attention from trained healthcare interpreters" (Practice Point; Chapter 5, v10 2022, p. 13).

"Patients with dysphagia should be offered regular therapy that includes skill and strength training in direct therapy (with food/fluids) and indirect motor therapy which capitalizes on the principles of neural plasticity to improve swallowing skills" (Practice Statement; Chapter 3, v10.7 2023, p. 7).

Individuals with suspected attention impairments, or those who "appear easily distracted or unable to concentrate," after stroke should receive a formal neuropsychological or cognitive assessment (Practice Statement; Chapter 5, v10 2022).

"Brain stimulation (transcranial direct current stimulation or repetitive transcranial magnetic stimulation), with or without traditional aphasia therapy, is not recommended in routine practice for improving speech and language function in chronic patients with aphasia and [should] only [be] used as part of a research framework" (Weak Recommendation Against; Chapter 5, v10 2022, p. 10).

"For stroke survivors with symptoms of unilateral neglect, cognitive rehabilitation (e.g., computerized scanning training, pen and paper tasks, visual scanning training, eye patching, mental practice) may be provided" (Weak Recommendation For; Chapter 5, v5.2 2018, p. 17).

Aphasia assessment and treatment should be offered as early as tolerated (Practice Statement; Chapter 5, v10 2022).

Individuals with dysphagia status post acute stroke should receive intervention early, to include "behavioral approaches such as swallowing exercises, environmental modifications, safe swallowing advice, and appropriate dietary modifications" (Strong Recommendation; Chapter 3, v10.7 2023, p. 7).

Individuals post-stroke should receive assistance and/or education on oral and dental hygiene, particularly if they have swallowing difficulty. Staff and care partners should be trained in assessing and managing oral hygiene (Strong Recommendation; Chapter 6, v10.3 2023 p. 5). Chlorhexidine in combination with oral hygiene programs may be used to decrease oral flora and gingiva bleeding, however, caution should be taked for individuals with dysphagia (Weak Recommendation; Chapter 6, v10.3 2023 p. 5).

Following stroke, a trained and qualified healthcare provider should formally assess any patient with suspected executive functioning impairment. Assessment should be conducted using valid and reliable tools and should examine behavioral symptoms (Practice Statement; Chapter 5, v10 2022).

Individuals with communication difficulty after right hemisphere stroke should receive comprehensive assessment. A management plan including family and/or care partner education/support/counseling should be provided, as needed (Practice Statement). Treatment may include: <ul> <li>prosodic treatments with motoric-imitative or cognitive-linguistic approaches; and</li> <li>"semantic-based treatment connecting literal and metaphorical senses to improve comprehension of conversational and metaphoric concept" (Practice Statement; Chapter 5, v10 2022, p. 14). </li> </ul>

Those who fail the swallow screen or demonstrate a deterioration in function should "have a comprehensive assessment of swallowing performed by a speech pathologist" (Weak Recommendation; Chapter 3, v10.7 2023, p. 6).

"People with acute stroke should have their swallowing screened, using a validate screening tool, by a trained healthcare professional" (Strong Recommendation; Chapter 3, v10.7 2023, p 6).

Any individual with memory impairment following stroke that is causing functional difficulty or difficulty in rehabilitation should receive a comprehensive assessment of memory from a qualified healthcare professional. The individual should: <ul> <li>have nursing and therapy sessions structured to take advantage of preserved memory ability and intact memory strategies;</li> <li>have therapy delivered in environments closely approximating the patient's home and community environment to aid in generalization; and</li> <li>be comprehensively taught external (e.g., notebooks, alerts, reminders, calendars) and internal (e.g., mnemonics, computerized training) memory strategies (Practice Statement; Chapter 5, v10 2022).</li> </ul>

Care partners and staff should be appropriately trained in oral hygiene care (including gum care and brushing teeth and/or dentures) and in swallowing and feeding techniques to assist individuals acutely post stroke (Practice Statement; Chapter 3, v10.7 2023 p. 7).

Individuals with apraxia after stroke may receive individually tailored treatment incorporating rate/rhythm and articulatory-kinematic approaches. Intervention may also incorporate: <ul> <li>"use of modelling and visual cueing;</li> <li>principles of motor learning to structure practice sessions;</li> <li>Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) therapy;</li> <li>self-administered computer programs that use multi-modal sensory stimulation; [and]</li> <li>for functional activities, the use of augmentative and alternative communication modalities such as gesture or speech-generating devices is recommended" (Weak Recommendation; Chapter 5, v10 2022, p. 14).</li> </ul>

"All acute stroke services should implement standardized protocols to manage fever, glucose, and swallowing difficulties in stroke patients" (Strong Recommendation; Chapter 3, v10.7 2023, p. 4).

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