Stroke Rehabilitation in Adults
National Clinical Guideline Centre. (2013).
London (United Kingdom): National Institute for Health and Care Excellence, (Clinical Guideline 162), 4-591.
This guideline provides recommendations for the long-term rehabilitation of stroke survivors ages 16 and older. The target audience of this guideline includes a variety of rehabilitation professionals including: physicians, nurses, physiotherapists, occupational therapists, and speech-language pathologists. Sections pertaining to cognition, communication, and swallowing are of particular interest to speech-language pathologists. Recommendations are based on interpretation of the available evidence, taking into consideration the benefits, harms, and costs. When no evidence was available or when evidence was of poor quality or conflicting, the recommendations are based on consensus from the guideline development group.
National Institute for Health and Care Excellence (United Kingdom)
<p>This guideline was reviewed with the following:</p>
<ul>
<li>National Institute for Health and Care Excellence. (2019). <em>2019 Surveillance of Stroke Rehabilitation in Adults (NICE Guideline CG162)</em>. Retrieved from <a class="ApplyClass" href="https://www.nice.org.uk/guidance/cg162/resources/2019-surveillance-of-stroke-rehabilitation-in-adults-nice-guideline-cg162-6723786637/chapter/Surveillance-decision?tab=evidence">www.nice.org.uk</a></li>
<li>National Institute for Health and Care Excellence. (2019). <em>Air Pollution: Outdoor Air Quality and Health</em> (Quality Standard 181). Retrieved from <a href="https://www.nice.org.uk/guidance/qs181">www.nice.org.uk</a></li>
</ul>
<p>Additionally, the data in this guideline are included in other documents which can be found in the Associated Article section.</p>
Individuals should be screened within 72 hours of the onset of stroke symptoms for communication impairments (i.e., aphasia or dysarthria) using a standardized screening protocol devised by the stroke rehabilitation service.
Attention training should be considered after stroke, particularly for individuals with right hemisphere damage. Treatments should focus on functional tasks; for example, managing the individual's own functional environment, or providing prompts relevant to functional tasks.
"Refer people with suspected communication difficulties after stroke to a speech and language therapist for detailed analysis of speech and language impairments and assessment of their impact" (p. 305).
"Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved" (p. 21). More than 45 minutes may be appropriate if the individual can participate and make progress, or shorter sessions (still 5 days per week) if he/she cannot participate for 45 minutes.
Individuals with persistent communication difficulties after stroke (i.e., aphasia or dysarthria) observed at the 6-month or annual review should be referred to a speech and language therapist for assessment.
Treatment for individuals with dysarthria or aphasia secondary to stroke "should be led and supervised by a specialist speech and language therapist working collaboratively with other appropriately trained people–for example, speech and language therapy assistants, carers and friends, and members of the voluntary sector" (pp. 282-283).
For individuals with stroke-induced dysphagia, "swallowing therapy could include compensatory strategies, exercises and postural advice" (p. 247).
When providing education, consider any impairments related to aphasia and/or cognition, as well as the emotional adjustment of the individual/family. Education should also include information about community-based communication and support groups and individuals should be encouraged to participate.
"Offer training in communication skills (such as slowing down, not interrupting, using communication props, gestures, drawing) to the conversation partners of people with aphasia after stroke" (p. 312).
Swallowing should be assessed in stroke patients in accordance with the <a class="ApplyClass" title="http://www.nice.org.uk/guidance" href="http://www.nice.org.uk/guidance/cg162/chapter/About-this-guideline#other-versions-of-this-guideline">NICE Stroke Clinical Guideline</a> recommendations.
It is recommended that individuals with communication difficulties following stroke be enabled to communicate their everyday needs and wishes and be provided with the support necessary to participate in everyday and major life decision-making. Also, it is recommended that environmental communication barriers be minimized for these individuals, for example by establishing clear signage and reducing background noise.
When treating visual neglect after right hemisphere stroke, use functional tasks with cues to scan to the neglected side (e.g., verbal cues or visual cues at the edge of a page of text).
"Screen people after stroke for cognitive deficits. Where a cognitive deficit is identified, carry out a detailed assessment using valid, reliable and responsive tools before designing a treatment programme" (p. 194).
"Assess memory and other relevant domains of cognitive functioning (such as executive functions) in people after stroke, particularly where impairments in memory affect everyday activity" (p. 201).
"Speech and language therapists should assess people with limited functional communication after stroke (i.e., individuals with aphasia or dysarthria) for their potential to benefit from using a communication aid or other technologies (for example, home-based computer therapies or smartphone applications)" and should provide communication aids and training to those who have the potential to benefit from their use (p. 283).
Individuals with communication difficulties after stroke (i.e., aphasia or dysarthria) should have opportunities for engagement in "conversation and social enrichment with people who have the training, knowledge, skills and behaviors to support communication. This should be in addition to the opportunities provided by families, carers and friends" (p. 283).
Attention deficits commonly occur in individuals with right hemisphere damage. When assessing attention impairments after stroke, use standardized assessments, and "behavioural observation to evaluate the impact of the impairment on functional tasks" (p. 210).
Persons with stroke should be screened on admission for swallowing, nutritional status, and hydration.
"Offer swallowing therapy at least 3 times a week to people with dysphagia after stroke who are able to participate, for as long as they continue to make functional gains" (p. 247).
Appropriately skilled and trained professionals should regularly monitor and reassess individuals with dysphagia after stroke who have been placed on modified texture diets in accordance with the <a class="ApplyClass" title="https://www.nice.org.uk/guidance" href="https://www.nice.org.uk/guidance/cg32">NICE Nutrition Support in Adults Clinical Guideline</a>.
<p>"Speech and language therapists should</p>
<ul>
<li>provide direct impairment-based therapy for communication impairments (for example, aphasia or dysarthria);</li>
<li>help the person with stroke to use and enhance their remaining language and communication abilities;</li>
<li>teach other methods of communicating, such as gestures, writing, and using communication props;</li>
<li>coach people around the person with stroke (including family members, carers and health and social care staff) to develop supportive communication skills to maximise the person's communication potential;</li>
<li>help the person with aphasia or dysarthria and their family or carer to adjust to a communication impairment;</li>
<li>support the person with communication difficulties to rebuild their identity; [and]</li>
<li>support the person to access information that enables decision-making" (p. 305). </li>
</ul>
Memory treatment should focus on functional tasks and may include increasing awareness of impairments, learning and using external strategies, and modifying the environment (e.g., environmental prompts or routine).
