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>.
<div>Trained professional (e.g., SLP, neuropsychologist) should administer a valid and reliable cognitive and perceptual screening tool to all adults status post stroke, ideally prior to hospital discharge. Individuals identified as having cognitive deficits should be referred for comprehensive neuropsychological evaluation (Practice Statement). </div>
<div>Cognitive rehabilitation may be used to improve memory function for adults with stroke-associated memory deficits in the short term. Strategies may include internal (e.g. association, mental rehearsal, rhymes) or external (e.g. diaries, alarms, mobile phone reminders) strategies (Weak Recommendation).</div>
<div>Stroke patients and their families and care partners should be educated on how to recognize the signs of stroke (i.e., Face, Arm, Speech, Time [FAST]) in order to encourage early presentation to the hospital in the case of a recurrent stroke. Clinicians should emphasize the need for education, information, and behavior change to address long-term stroke prevention (Practice Statement). </div>
<div>Stroke patients should be provided with comprehensive hospital discharge plans that address their specific rehabilitation needs. These plans should be developed with the patient and their family or care partners prior to discharge (Strong Recommendation). </div>
<div>Stroke patients should be offered self-management interventions within the first four months of discharge to the community. Currently, the strongest evidence base exists for the Take Charge After Stroke self-management intervention (Strong Recommendation)<br><br>Prior to hospital discharge, stroke patients who are cognitively able and their family and care partners should be provided information about the availability of generic self-management programs. They should be supported to access such programs once they have returned to the community. Stroke-specific programs may be provided for those with more specialized needs. Collaboratively developed self-management care plans may be used to improve self-management skills (Weak Recommendation).</div>
<div>Stroke patients should be admitted to a hospital and treated in an interdisciplinary stroke unit (Strong Recommendation).</div>
<div>Every stroke patient should receive rehabilitation needs assessment within 24–48 hours of admission to the stroke unit. This should be provided by members of the interdisciplinary team, using an appropriate process/tool. All patients identified as having rehabilitation needs should be referred to a rehabilitation service. The needs or lack of needs should be documented by rehabilitation service providers alongside information about whether or not there are appropriate rehabilitation services available to meet these needs" (Practice Point).</div>
<div>For individuals with stroke-associated dysphagia, surface neuromuscular electrical stimulation (NMES) should only be delivered by clinicians trained and experienced in delivering this intervention. NMES should be applied in accordance with published parameters in research. Pharyngeal electrical stimulation should not be used for routine clinical use (Weak Recommendation).</div>
<div>Dysphagia screening should be completed within four hours of an acute stroke patient arriving to the hospital. Screening should occur before the patient is given any oral food, fluid, or medication (Practice Statement). Until a safe swallowing method is determined for oral intake, stroke patients with dysphagia should have their nutrition and hydration assessed and managed. Early alternative non-oral routes may be considered (Practice Statement).</div>
<div>Stroke patients with dysphagia who are on modified liquids or solids should be regularly monitored regarding their intake and diet tolerance due to the increased risk of malnutrition and dehydration (Practice Statement). Any patients with persistent weight loss, dehydration, and/or recurrent chest infection following stroke should be reviewed for dysphagia urgently (Practice Statement).</div>
<div>Clinicians may provide interventions to promote adherence with medication regimens to all patients with stroke. These interventions may include combinations of the following elements:</div>
<ul>
<li><span style="color: #333333;">reminders, telephone follow-up, or dose administration aids; </span></li>
<li><span style="color: #333333;">use of self-monitoring, reinforcement, counselling, motivational interviewing, family therapy, or supportive care; </span></li>
<li><span style="color: #333333;">development of self-management skills; </span></li>
<li><span style="color: #333333;">"modification of dysfunctional beliefs about medication"; and </span></li>
<li><span style="color: #333333;">information and education regarding medication in the hospital and in the community (Weak Recommendation). </span></li>
</ul>
<div>Following stroke, patients should be encouraged actively practice therapy tasks outside of scheduled sessions, including:</div>
<ul>
<li><span style="color: #333333;">self-directed and independent practice; or</span></li>
<li><span style="color: #333333;">semi-supervised, assisted practice involving family, care partners, and friends, as appropriate (Practice Statement).</span></li>
</ul>
<div>If appropriate, coordinated home-based stroke services are available, patients with mild to moderate stroke should be offered early supported discharge services (Strong Recommendation). Home-based rehabilitation may be considered as a preferred model community-based rehabilitation. If home rehabilitation is unavailable, stroke patients requiring rehabilitation should receive center-based care (Weak Recommendation).</div>
<div>Throughout the care process, health professionals should involve stroke survivors and their families and care partners in the goal-setting process unless they choose not to participate. These goals should be:</div>
<div>
<ul>
<li> well-defined, specific and challenging;</li>
<li>reviewed and updated regularly; and</li>
<li>patient-centered, clearly communicated, and documented so that the patients, their families and care partners, and other members of the rehabilitation team remain informed (Strong Recommendation).</li>
</ul>
</div>
<div>The following recommendations were made regarding screening of patient status-post stroke:</div>
<ul>
<li><span style="color: #333333;">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). </span></li>
<li><span style="color: #333333;">Any patients with suspected communication deficits should receive a formal and comprehensive assessment by a specialist clinician to determine the nature and type of their communication disorder (Practice Statement). </span></li>
<li><span style="color: #333333;">Any patient suspected as having cognitive deficits should be referred for comprehensive neuropsychological assessment (Practice Statement).</span></li>
</ul>
<div>Communication partner training should be provided to healthcare professionals and volunteers working with people with aphasia following stroke (Strong Recommendation). Communication partner training and education may also be provided to the patient's care partners or family (Weak Recommendation).</div>
<div>For adults with aphasia, clinicians should:</div>
<ul>
<li><span style="color: #333333;">document the provisional aphasia diagnosis;</span></li>
<li><span style="color: #333333;"> explain and discuss the nature of any language impairment with the patient, their family or care partners, and treating team;</span></li>
<li><span style="color: #333333;"> discuss and teach communication strategies or techniques; </span></li>
<li><span style="color: #333333;">identify goals for therapy, developing and providing a tailored intervention plan in collaboration with the patient and their family and care partner; </span></li>
<li><span style="color: #333333;">reassess the patient's goals and treatment plan at appropriate time intervals; and</span></li>
<li><span style="color: #333333;">use alternative means of communication (e.g., gesture, drawing, writing, use of augmentative and alternative communication devices) as appropriate (Practice Statement).</span></li>
</ul>
<div>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 re-assessed over time (Practice Statement).</div>
<div>Telepractice may be used as an alternative approach when delivering stroke rehabilitation services, especially in cases where the patient does not have ready access to specialist rehabilitation in the community. Telepractice may also be considered as an adjunct to in-person therapy. However, specific interventions should only be delivered via telehealth if that have previously shown to be beneficial (Weak Recommendation).</div>
<div>The following is recommended for post-stroke fatigue:</div>
<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)</li>
</ul>
<div>Behavioral changes after stroke can impact a patient's quality of life and ability to engage in meaningful activities. The impact of behavioral changes on relationships, employment, and leisure should be assessed and addressed across the lifespan. Following stroke, patients and their families and care partners should receive individually tailored interventions for any personality or behavioral changes. This may include positive behavior support programs, anger-management therapy, and rehabilitation training and support in management of complex and challenging behaviors (Practice Statement).</div>
<div>Stroke education for patients and their families or care partners should be provided throughout different stages of the recovery process and should 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).</div>
<div>Following acute stroke, patients and their families or care partners should be given the opportunity to identify and discuss their post-discharge needs (e.g., physical, emotional, social, financial) with relevant members of the interdisciplinary team.</div>
<div>
<ul>
<li>Discharge planning should begin as soon as possible following hospital admission.</li>
<li>All necessary support services, treatments, and equipment should be organized prior to discharge.</li>
<li>A discharge planned may be used to coordinate comprehensive discharge plans for stroke patients. </li>
<li>A post-discharge care plan should be developed in collaboration with the patient and their family or care partners.</li>
<li>The patient's primary healthcare team and anyone providing community-based services to the patient should be informed prior to discharge. </li>
<li>This plan should include:
<ul>
<li>any relevant community services;</li>
<li>self-management strategies such as information and advice on medications and compliance and a review of goals and therapy to continue at home;</li>
<li>education regarding stroke support services;</li>
<li>the coordination of any further rehabilitation or outpatient appointments; and</li>
<li>the provision of an appropriate contact number for any post-discharge needs (Practice Statement).</li>
</ul>
</li>
</ul>
</div>
<div>The following is recommended for return to driving following stroke or transient ischemic attack (TIA):</div>
<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 driving until both the mandated period of non-driving has elapsed and any stroke deficits precluding safe driving have resolved. This should be confirmed by their treating doctors and clinicians. Minimum periods of non-driving as determined by the relevant national or state standards must be followed.</li>
<li>If the treating clinician is uncertain whether persisting motor, sensory or cognitive changes preclude safe driving, the patient should be referred for a driving assessment by a specialist occupational therapist.</li>
<li>Patients should be screened and assessed for any ongoing neurological deficits that could influence safe driving. Any visual, cognitive, physical, and behavioral assessment findings should be documented (Practice Statement).</li>
</ul>
<div>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.</div>
<div>
<ul>
<li>Those who wish to return to work should be provided with assessment in order to determine current abilities relative to work demands.</li>
<li>These patients should be offered assistance in resume writing, interventions to aid in either obtainment or return to work (e.g., site visits and workplace interventions).</li>
<li> Referral to a supported employment service should be offered (Weak Recommendation).</li>
</ul>
</div>
<div>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).</div>
<div>Individuals with stroke-associated executive functioning impairment should receive information in ways that consider their specific deficits (Practice Statement).</div>
<div>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. They should also be monitored during mealtimes to support attention and intake of food on both sides of the plate (Practice Statement).</div>
<div>Clinicians may provide meta-cognitive strategies and cognitive training to individuals with stroke-associated cognitive impairment (Weak Recommendation).</div>
<div>Individuals with dysarthria after stroke may receive individually tailored interventions, which may include:</div>
<ul>
<li><span style="color: #333333;">speech production tasks that target connected speech; and </span></li>
<li><span style="color: #333333;">strategies to reduce speaking rate, emphasize articulatory placement, or increase loudness (Weak Recommendation).</span></li>
</ul>
<div>The following is recommended regarding aphasia therapy in adults status post stroke:</div>
<ul>
<li><span style="color: #333333;">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). </span></li>
<li><span style="color: #333333;">Aphasia therapy should be provided within the first four weeks of stroke to maximize language recovery (Strong Recommendation).</span></li>
<li><span style="color: #333333;">In the first six week post stroke, language therapy sessions ranging from 30-45 minutes two-three days per week may be provided. Additional therapy sessions during this early acute stage is unlikely to yield any additional benefit regarding language recovery (Weak Recommendation).</span></li>
<li><span style="color: #333333;">In the chronic phase (i.e., more than 6 months post onset), intensive, therapist-led aphasia therapy (i.e., at least 10 hours/week) in individual or group formats for 3 weeks in combination with at least 5 hours a week of self-managed training may be used to improve aphasia (Weak Recommendation).</span></li>
</ul>
<div>Relevant interdisciplinary team members should educate and train stroke patients' care partners and family before discharge. As appropriate, this training should include 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).</div>
<div>Participation barriers for people with aphasia should be addressed through:</div>
<div>
<ul>
<li>communication partners training;</li>
<li>raising awareness of and educating patients, care partners, and staff about aphasia to reduce negative attitudes;</li>
<li>promoting access and inclusion by providing aphasia-friendly formats or other environmental adaptations;</li>
<li>the provision of trained healthcare interpreters for people with aphasia from culturally and linguistically diverse backgrounds, as needed (Practice Point).</li>
</ul>
</div>
<div>Stroke patients with dysphagia should be offered regular swallowing therapy that includes skill and strength-based training including both direct treatments with food/fluids and indirect motor therapy which harnesses the principles of neural plasticity to improve swallowing (Practice Statement).</div>
<div>Cognitive rehabilitation may be provided to adults with attention and concentration issues status post stroke. Attention-based exercises and leisure activities may be provided (Weak Recommendation). </div>
<div>Bain stimulation (e.g., transcranial direct current stimulation, repetitive transcranial magnetic stimulation), with or without traditional aphasia therapy, is not recommended as a routine practice for improving speech and language function in patients with chronic aphasia. These treatments should only be used in research (Weak Recommendation).</div>
<div>Cognitive rehabilitation may be provided for adults with stroke-associated unilateral neglect (Weak Recommendation).</div>
<div>Adults with stroke-associated aphasia should be offered language assessment and treatment as early as tolerated (Practice Statement).</div>
<div>Individuals with dysphagia status post acute stroke should receive early behavioral dysphagia treatment, which may include approaches such as swallowing exercises, environmental modifications, safe swallowing advice, and appropriate dietary modifications (Strong Recommendation).</div>
<div>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). Chlorhexidine in combination with oral hygiene programs may be used to decrease oral flora and gingiva bleeding, however, caution should be taken for individuals with dysphagia (Weak Recommendation).</div>
<div>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. Providers should tailor any education and training to account for cognitive deficits in individuals identified as having executive functioning deficits(Practice Statement).</div>
<div>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:</div>
<ul>
<li><span style="color: #333333;">prosodic treatments with motoric-imitative or cognitive-linguistic approaches; and</span></li>
<li><span style="color: #333333;">semantic-based treatment with explicit training in the comprehension of literal and figurative/metaphorical language (Practice Statement). </span></li>
</ul>
<div>Stroke patients who fail a swallow screen or demonstrate a deterioration in function should have a comprehensive swallowing assessment performed by a speech pathologist (Weak Recommendation).</div>
<div>Adults with acute stroke should have their swallowing screened by a trained healthcare professional using a validated tool (Strong Recommendation).</div>
<p>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:</p>
<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 how to utilize external (e.g., notebooks, alerts, reminders, calendars) and internal (e.g., mnemonics, computerized training) memory strategies (Practice Statement).</li>
</ul>
<div>Care partners and staff should be appropriately trained in:</div>
<div>
<ul>
<li> oral hygiene care, including gum care and brushing teeth and/or dentures); and</li>
<li>swallowing and feeding techniques to assist individuals acutely post stroke (Practice Statement).</li>
</ul>
</div>
<div>Individuals with apraxia after stroke may receive individually tailored treatment incorporating rate/rhythm and articulatory-kinematic approaches. Intervention may also incorporate:</div>
<ul>
<li>the use of modelling and visual cues;</li>
<li>principles of motor learning;</li>
<li>Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) therapy;</li>
<li>self-administered computer programs that incorporate multi-modal sensory stimulation; </li>
<li>the use of augmentative and alternative communication modalities (e.g., gesture, speech-generating devices) for functional activities (Weak Recommendation).</li>
</ul>
<div>Acute stroke services should follow standardized protocols to manage swallowing difficulties in stroke patients (Strong Recommendation).</div>
