American Speech-Language-Hearing Association

EBP Compendium: Summary of Clinical Practice Guideline

Royal College of Physicians; Stroke Association; Broehringer Ingelheim; Merck Sharp & Dohme; Sanofi-Sythelapo & Bristol-Myers Squibb
National Clinical Guidelines for Stroke

Intercollegiate Stroke Working Party (2008).
London (United Kingdom): Royal College of Physicians, 3rd Edition, 187 pages.

AGREE Rating: Highly Recommended

Description:

This guideline provides recommendations for the management of stroke across all populations. The audiences intended for this guideline include clinical staff, managers, commissioners involved in the purchasing of services, patients with stroke, relatives, and friends. The guideline contains a concise guide with specific recommendations for speech and language therapy, beginning on page 140.  

Recommendations:

  • Assessment/Diagnosis
    • Assessment Areas
      • Swallowing
        • Individuals with acute stroke should have their swallowing screened at admission by a trained professional prior to being given food, fluid, or medication orally. If the admission screen indicates a potential swallowing impairment, a specialist assessment should be conducted ideally within 24 hours and not more than 72 hours after admission. (pp. 140-141).
        • Individuals with suspected aspiration, requiring tube feeding or dietary modification should be reassessed and considered for instrumental evaluation after three days and should be referred for dietary advice (p. 141).
      • Language - “Any patient with left hemisphere cerebral damage should be screened for aphasia using a formal screening tool such as the Frenchay Aphasia Screening Test or Sheffield Aphasia Screening Test” (p. 141). If the patient is suspected to have aphasia after screening, he or she should undergo a formal assessment of communication and language by a speech-language therapist (p. 141).
      • Speech
        • “Any patient whose speech is unclear or unintelligible so that communication is limited or unreliable should be assessed by a speech and language therapist to determine the nature and cause of the speech impairment” (p. 142).
        • “Any patient who has marked difficulty articulating words with adequate language function should be formally assessed for apraxia of speech and treated to maximise intelligibility” (p. 142).
    • Assessment Instruments
      • Language
        • Aphasia Screening Tests
          • “Any patient with left hemisphere cerebral damage should be screened for aphasia using a formal screening tool such as the Frenchay Aphasia Screening Test or Sheffield Aphasia Screening Test” (p. 141).
          • If the patient is suspected to have aphasia after screening, he or she should undergo a formal assessment of communication and language by a speech-language therapist (p. 141).
      • Swallowing
        • FEES/Videofluoroscopy - “Instrumental direct investigation of oropharyngeal swallowing mechanisms (e.g. by videofluoroscopy or flexible endoscopic evaluation of swallowing) should only be undertaken in conjunction with a speech and language therapist with specialism is dysphagia if needed to direct an active treatment/rehabilitation technique for their swallowing difficulties, or to investigate the nature and causes of aspiration” (p. 143).
  • Treatment
    • Speech
      • General Findings
        • Individuals with severe dysarthria that limits communication should be taught techniques to improve speech clarity and be assessed for alternative and augmentative communication aids (p. 142).
        • Family and staff who work closely with the dysarthric individual should be taught techniques to assist the individual in their communication (p. 142).
      • AAC Treatment - The apraxic individual should be assessed for and provided appropriate augmentative and alternative communication aids if communication impairment is severe and cognition is reasonably intact (p. 142).
      • Apraxia Treatment - “Any patient who has marked difficulty articulating words with adequate language function should be formally assessed for apraxia of speech and treated to maximise intelligibility” (p. 142).
    • Language
      • General Findings
        • The speech-language pathologist should explain the aphasia impairment to the patient, family, and healthcare team and should establish the most appropriate means of communication. The nature and severity of the impairment should be re-assessed at regular intervals (p. 141).
        • If aphasia persists for more than two weeks the individual should be given treatment to reduce specific language impairments, be considered for intensive speech and language therapy (2-8 hrs/wk, as tolerated), and be assessed for alternative communication means (pp. 141-142).
      • Augmentative and Alternative Communication - If aphasia persists for more than two weeks the individual should be given treatment to reduce specific language impairments, be considered for intensive speech and language therapy (2-8 hrs/wk, as tolerated), and be assessed for alternative communication means (pp. 141-142).
    • Swallowing
      • General Findings
        • “All patients who are not swallowing, including those with tube feeding should have oral and dental hygiene maintained (by the patient or carers) through regular (four-hourly)
        • Brushing of teeth, dentures and gums with a suitable cleaning agent (toothpaste or chlorhexidine gluconate dental gel)
        • Removal of secretions” (p. 143).
        • “All patients with swallowing difficulties and/or facial weakness who are taking food orally should be taught or helped to clean their teeth or dentures after each meal” (p. 143).
      • Diet Modification - Individuals with dysphagia should receive foods and fluids in a form that can be swallowed without aspiration (p. 141).
      • Compensatory Treatment & Oral-Motor Treatment - Patients with swallowing impairments persisting for one week or more should be considered for an oro-pharyngeal swallowing rehabilitation program which includes compensatory strategies and/or restorative strategies (p. 143).
      • Tube Feeding - Those individuals who are unable to safely take fluids and nutrition orally, should receive tube feeding with a nasogastric tube, nasal bridle tube or gastrostomy tube (p. 141).
  • Service Delivery
    • Dosage
      • If aphasia persists for more than two weeks the individual should be given treatment to reduce specific language impairments, be considered for intensive speech and language therapy (2-8 hrs/wk, as tolerated), and be assessed for alternative communication means (pp. 141-142).

Keywords: Stroke

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Added to Compendium: November 2011

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