American Speech-Language-Hearing Association

EBP Compendium: Summary of Clinical Practice Guideline

Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
RCSLT Clinical Guidelines: 5.12 Aphasia

Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.

AGREE Rating: Highly Recommended

Description:

This guideline provides recommendations for the assessment and treatment of individuals with aphasia. These guidelines are specific to speech-language pathologists. Recommendations are based on randomized controlled trials (Level A Evidence), well-conducted clinical studies (Level B Evidence), or expert opinion (Level C Evidence).

Recommendations:

  • Assessment/Diagnosis
    • Assessment Areas
      • Language
        • Assessment should be purposeful and may occur during any stage of intervention. Assessment may incorporate interview, conversation, observation, and formal and informal assessment tools (Level C Evidence) (p. 99).
        • The assessment should consider the impact of the communication disability on the lives of the individual and close others and may include an assessment of the skills of the communication partner(s) (Level B Evidence) (p. 100).
        • Assessment should focus on:
          • “The nature and extent of the speech and language impairment and level of preserved abilities” (Level B Evidence) (p. 99);
          • “Functional and pragmatic aspects of communication, including compensatory strategies” (Level B Evidence) (p. 99); and
          • “Psychosocial well-being” (Level B Evidence) (p. 99).
        • “Careful assessment is needed to identify the nature of the sentence processing impairment. This should be hypothesis driven, and may include tests of verb and sentence comprehension, and analyses of verb, sentence and narrative production” (Level B Evidence) (p. 106).
        • “Pre and post therapy assessment should explore speech production in open conditions, such as narrative and conversation, as well as in constrained conditions, such as picture description” (Level B Evidence) (p. 107).
      • Auditory Processing
        • “Careful assessment is required to identify the presence, nature and severity of an auditory processing impairment, which may be difficult to detect in conversation or informal tasks” (Level B Evidence) (p. 101).
        • Assessment should consider the individual’s skills in speech sound discrimination, spoken word recognition and spoken word comprehension, as well as the possibility of coexisting hearing loss or central auditory processing disorder (Level B Evidence) (p. 101).
      • Reading
        • Prior to word reading, the pre-morbid literacy, visual acuity, and visual neglect need to be considered (Level B Evidence) (p. 104).
        • An assessment of reading must consider how the individual uses reading in everyday life in addition to his or her orthographic, phonological, and semantic processing of written words. Assessment may involve letter and word recognition, reading aloud, reading comprehension, letter use, and use of words and non-words (Level B Evidence) (p. 104).
      • Writing - "A thorough assessment needs to consider how the individual uses writing in their everyday life. It also needs to incorporate analyses of semantic, orthographic and phonological processing of written words” (Level C Evidence) (p. 105).
  • Treatment
    • Speech
      • General Findings - “For spoken output difficulties that are caused primarily by difficulties in accessing word-forms, therapy should include tasks that focus on producing spoken output or silently accessing phonological word-forms. These may include, for instance, phonemic cueing of spoken output, cueing spoken output with written letters, repetition, rhyme judgment, and reading aloud” (Level B Evidence) (p. 103).
      • Apraxia Treatment - “For spoken output difficulties that are caused primarily by difficulties in accessing and sequencing the sounds within words, therapy should include tasks that focus on the structure of word forms. These might include, for instance, listening to differences between spoken words, repeating words of increasing length, strengthening links between written spellings and spoken word-forms, and developing skills in self-monitoring of spoken output” (Level B Evidence) (p. 104).
    • Language
      • General Findings
        • "Therapists should aim to… facilitate changes to the environment by, for example, altering room layout and reducing background noise” (Level B Evidence) (p. 100).
        • “Where impairments are primarily at the level of speech sound perception, therapy should aim to improve discrimination of speech sounds” (Level B Evidence) (p. 102).
        • “Where impairments are primarily at the level of spoken word comprehension, therapy should aim to improve access to word meanings” (Level B Evidence) (p. 102).
        • “For spoken output difficulties that involve difficulties in processing word-meanings, therapy should include tasks that focus on semantic processing. These might, for instance, include semantic cueing of spoken output, semantic judgments, categorization and word-to-picture matching” (Level B Evidence) (p. 103).
        • “To promote generalization of learned strategies, therapists should involve communication partners in therapy and conduct therapy within natural communication environments” (Level B/C Evidence) (p. 108).
      • Computer-Based Treatment - “Computer-based therapy offers the potential to provide intensive home-based therapy with minimal clinician input. Improvements in performance over a number of communicative modalities can occur” (Level A Evidence) (p. 110).
      • Multi-Modal Treatment - “Specific training in the development and/or refinement of non-verbal communication strategies is required for these to be used efficiently and effectively. Ideally these strategies should be used within a ‘Total Communication’ approach, that promotes the flexible use of multi-modality communication to improve communicative effectiveness” (Level B Evidence) (p. 108).
      • Reading Treatment
        • “When there is a letter recognition deficit, therapy should aim to improve the speed and efficiency of letter identification” (Level B Evidence) (p. 105).
        • “When there is a deficit in recognizing irregular written words, semantic approaches are helpful” (Level B Evidence) (p. 105).
        • "When there is a deficit in recognising written words, semantic approaches are helpful” (Level B Evidence) (p. 105).
        • "When there is a deficit in accessing phonology from orthography, retraining grapheme to phoneme correspondence can be helpful, in some cases in combination with a semantic component. If the client has difficulty blending phonemes into syllables, bigraph-phoneme correspondence should be considered” (Level B Evidence) (p. 105)
      • Writing Treatment - “Once the level of breakdown in writing has been established, therapy can focus on training the impaired component or using intact mechanisms to compensate for the impairment” (Level B Evidence) (p. 105).
      • Patient Perspectives
        • Several experiential themes were identified by service users. These include: 
        • “The therapy relationship should be viewed as a partnership” (p. 110);
        • “Aphasia should be fully explained, as soon as possible, to the individual and the family” (p. 110);
        • “The explanation should be repeated frequently to the individual and the family” (p. 110);
        • “Such explanations should be accompanied by written information- however, this information should be aphasia- and user-friendly” (p. 110).
        • “There is a need for ongoing support once the individual has been discharged from therapy, therefore the therapist should provide information regarding support groups and opportunities to meet others with aphasia” (p. 110).
  • Service Delivery
    • Format - “There should be opportunities for individuals to participate in groups as well as in individual therapy” (Level A Evidence) (p. 109). 

Keywords: Aphasia; Stroke

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Added to Compendium: November 2010

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