Summary of the Clinical Practice Guideline

Article Citation

National Clinical Guideline for Stroke

Royal College of Physicians. (2016).
London (United Kingdom): Royal College of Physicians, (5th Edition), i-151.
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Royal College of Physicians (United Kingdom)

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Article Details

Description

This is the fifth edition of the UK National Clinical Guidelines for Stroke. This guideline is an update of the 2012 version providing recommendations for the management of stroke in adult populations. The audiences intended for this guideline include clinical staff, managers, commissioners involved in the purchasing of services, as well as patients with stroke and their caregivers. Of particular interest to speech-language pathologists are recommendations on swallowing, communication, and cognition management. Specific recommendations were made based on the nature and strength of the evidence, or by using a formal consensus approach by the guideline working group.

Recommendations from This Guideline

What are Recommendations?

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Assessment

Assessment, treatment, and education materials for the individual with post-stroke aphasia should be provided in his/her preferred language. 

Keywords: Bilingual Considerations, Aphasia, Bilingual Considerations, Education/Training, Education/Counseling

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

Individuals with post-stroke communication difficulty should be evaluated by a speech-language pathologist. As needed, education should be provided to the individual, his/her family/caregivers, and the multidisciplinary team on the impairment and its impact. The individual should be evaluated for assistive devices as needed by "an appropriately trained, experienced clinician" (p. 65).  Reassessment should only occur within the first four months if needed for decision-making or assessment of mental capacity. 

Keywords: Stroke, Age, Provider, Timing, Aphasia, Adults, Education/Training

Treatment

Assessment, treatment, and education materials for the individual with post-stroke aphasia should be provided in his/her preferred language. 

Keywords: Bilingual Considerations, Aphasia, Bilingual Considerations, Education/Training, Education/Counseling

Education for communication partners should be provided by a speech-pathologist in order to promote the person with aphasia's participation in rehabilitation and the community. Communication partners include caregivers, family, and "health and social care staff" (p. 66).  

Keywords: Stroke, Provider, Provider, Aphasia, Education/Training, Education/Counseling

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

Service Delivery

Education for communication partners should be provided by a speech-pathologist in order to promote the person with aphasia's participation in rehabilitation and the community. Communication partners include caregivers, family, and "health and social care staff" (p. 66).  

Keywords: Stroke, Provider, Provider, Aphasia, Education/Training, Education/Counseling

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

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Assessment

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

"People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to [maximize] articulation of key words to improve speech intelligibility" (p. 67). 

Keywords: Apraxia

Treatment

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

"People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to [maximize] articulation of key words to improve speech intelligibility" (p. 67). 

Keywords: Apraxia

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Assessment

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

If an individual's speech is unclear or unintelligible post-stroke, he/she should receive evaluation from a speech-language pathologist. Education should be provided as needed to the individual, his/her family/caregivers, and multidisciplinary team as to the impairment and its impact. If speech is unintelligible, the individual should be evaluated for augmentative and alternative communication. 

Keywords: Provider, Provider, Age, Diagnosis/Condition, Adults, Education/Training, Dysarthria, Dysarthria

Individuals with post-stroke communication difficulty should be evaluated by a speech-language pathologist. As needed, education should be provided to the individual, his/her family/caregivers, and the multidisciplinary team on the impairment and its impact. The individual should be evaluated for assistive devices as needed by "an appropriately trained, experienced clinician" (p. 65).  Reassessment should only occur within the first four months if needed for decision-making or assessment of mental capacity. 

Keywords: Stroke, Age, Provider, Timing, Aphasia, Adults, Education/Training

Treatment

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

Go to Map

Assessment

If an individual's speech is unclear or unintelligible post-stroke, he/she should receive evaluation from a speech-language pathologist. Education should be provided as needed to the individual, his/her family/caregivers, and multidisciplinary team as to the impairment and its impact. If speech is unintelligible, the individual should be evaluated for augmentative and alternative communication. 

Keywords: Provider, Provider, Age, Diagnosis/Condition, Adults, Education/Training, Dysarthria, Dysarthria

Treatment

Individuals with post-stroke dysarthria should "be trained in techniques to improve the clarity of their speech" (p. 66), and their communication partners should receive training in assisting with communication. 

Keywords: Education/Training, Dysarthria

Service Delivery

If an individual's speech is unclear or unintelligible post-stroke, he/she should receive evaluation from a speech-language pathologist. Education should be provided as needed to the individual, his/her family/caregivers, and multidisciplinary team as to the impairment and its impact. If speech is unintelligible, the individual should be evaluated for augmentative and alternative communication. 

Keywords: Provider, Provider, Age, Diagnosis/Condition, Adults, Education/Training, Dysarthria, Dysarthria

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Screening

Individuals with acute stroke should be screened by a trained healthcare professional, using a validated tool, "within four hours of arrival at hospital and before being given any oral food, fluid or medication" (p. 49). 

Keywords: Setting, Timing, Setting (e.g. Acute/Outpatient), Timing, Dysphagia, Stroke

Individuals with residual neurological symptoms or signs of acute stroke or transient ischemic attack (TIA) should be NPO (nil per os/nothing by mouth) until they have received dysphagia screening from "a specifically trained healthcare professional" (p. 35). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

"End-of-life (palliative) care for people with stroke should include an explicit decision not to impose burdensome restrictions that may exacerbate suffering. In particular, this may involve a decision, taken together with the person with stroke, those close to them and/or a palliative care specialist, to allow oral food and/or fluids despite a risk of aspiration" (p. 30).

Keywords: Dysphagia, Stroke

Assessment

Individuals with post-stroke difficulty self-feeding should be evaluated and provided verbal assistance as needed "to promote independent and safe feeding" (p. 86). 

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or [fiberoptic] endoscopic evaluation of swallowing)" (p. 86). Individuals who require these assessments should receive them only:
  • "in conjunction with a specialist in dysphagia management; 
  • to investigate the nature and causes of aspiration; 
  • to direct an active treatment/rehabilitation [program] for swallowing difficulties" (p. 86). 

Keywords: Endoscopy, Fluoroscopy, Provider (SLP/Caregiver), Provider, Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

Individuals with dysphagia after acute stroke should receive a comprehensive, specialist assessment of swallowing. 

Keywords: Provider (SLP/Caregiver), Setting, Provider, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

The admission pathway of acute stroke services should include, among other services, management protocols for rehabilitation and swallowing assessment. 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Stroke

Treatment

"People with swallowing difficulty after stroke should be provided with written guidance for all staff/carers to use when feeding or providing fluids" (p. 86). 

Keywords: Education/Training, Education/Training (Includes Oral Hygiene), Education/Training (includes Oral Hygiene), Dysphagia, Stroke

Individuals with post-stroke difficulty self-feeding should be evaluated and provided verbal assistance as needed "to promote independent and safe feeding" (p. 86). 

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering" (p. 71). 

Keywords: Diet Modification, Diet Modification, Dysphagia, Stroke

"Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration" (p. 49). When lying or sitting down, these individuals "should be positioned to [minimize] the risk of aspiration" (p. 50). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

"End-of-life (palliative) care for people with stroke should include an explicit decision not to impose burdensome restrictions that may exacerbate suffering. In particular, this may involve a decision, taken together with the person with stroke, those close to them and/or a palliative care specialist, to allow oral food and/or fluids despite a risk of aspiration" (p. 30).

Keywords: Dysphagia, Stroke

Service Delivery

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or [fiberoptic] endoscopic evaluation of swallowing)" (p. 86). Individuals who require these assessments should receive them only:
  • "in conjunction with a specialist in dysphagia management; 
  • to investigate the nature and causes of aspiration; 
  • to direct an active treatment/rehabilitation [program] for swallowing difficulties" (p. 86). 

Keywords: Endoscopy, Fluoroscopy, Provider (SLP/Caregiver), Provider, Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

"Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration" (p. 49). When lying or sitting down, these individuals "should be positioned to [minimize] the risk of aspiration" (p. 50). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals with dysphagia after acute stroke should receive a comprehensive, specialist assessment of swallowing. 

Keywords: Provider (SLP/Caregiver), Setting, Provider, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals with residual neurological symptoms or signs of acute stroke or transient ischemic attack (TIA) should be NPO (nil per os/nothing by mouth) until they have received dysphagia screening from "a specifically trained healthcare professional" (p. 35). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

The admission pathway of acute stroke services should include, among other services, management protocols for rehabilitation and swallowing assessment. 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Stroke

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Assessment

Individuals with stroke affecting non-dominant cerebral hemisphere should be assessed for spatial awareness using standardized measures. Assessment should include impact of deficits on functional tasks. 

Treatment

Individuals with neglect post stroke should:
"‒ have the impairment explained to them, their family/carers and the multidisciplinary team;
‒ be trained in compensatory strategies to reduce the impact on their activities;
‒ be given cues to draw attention to the affected side during therapy and nursing activities;
‒ be monitored to ensure that they do not eat too little through missing food on one side
of the plate; 
‒ be offered interventions aimed at reducing the functional impact of the reduced
awareness (e.g. visual scanning training, limb activation, sensory stimulation, eye
patching, prism wearing, prism adaptation training, mirror therapy, galvanic vestibular
stimulation, transcranial magnetic stimulation), ideally in the context of a clinical trial" (p.63).

Keywords: Visuospatial Treatments (e.g. Visual Scanning)

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Screening

In regards to cognitive screening and assessment after stroke,
  • "People with stroke should be considered to have at least some cognitive impairment in the early phase. Routine screening should be undertaken to identify the person’s level of functioning, using [standardized] measures" (p. 59).
  • Individuals who are not making expected progress in rehabilitation should receive cognitive assessment to determine whether cognitive impairments are a factor. Results should be shared with the individual, family, and multidisciplinary team.
  • Individuals with communication impairments "should receive a cognitive assessment using valid assessments in conjunction with a speech and language therapist. Specialist advice should be sought if there is uncertainty about the interpretation of cognitive test results" (p. 59). 
  • Safety risks associated with cognitive impairments should be assessed when individuals with acute cognitive impairment transfer care, including potential effects on decision-making. Results should be shared with the primary care team.
  • Full cognitive assessment is recommended for individuals returning to driving or work. 
  • Severe or persistent post-stroke cognitive impairments "should receive specialist assessment and treatment from a clinical neuropsychologist/clinical psychologist" (p. 59). 

Keywords: Cognitive/Linguistic Deficits

Individuals with acute stroke should be screened by a trained healthcare professional, using a validated tool, "within four hours of arrival at hospital and before being given any oral food, fluid or medication" (p. 49). 

Keywords: Setting, Timing, Setting (e.g. Acute/Outpatient), Timing, Dysphagia, Stroke

Individuals with residual neurological symptoms or signs of acute stroke or transient ischemic attack (TIA) should be NPO (nil per os/nothing by mouth) until they have received dysphagia screening from "a specifically trained healthcare professional" (p. 35). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals should be screened for cognitive impairment through observation and validated tools. Screens should occur at the following time periods:
  • "Within six weeks of stroke (in the acute phase of rehabilitation and at the transfer of care into post-acute services)" (p. 27);
  • At six months; and
  • At 12 months. 

Keywords: Timing, Cognitive/Linguistic Deficits

Assessment

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or [fiberoptic] endoscopic evaluation of swallowing)" (p. 86). Individuals who require these assessments should receive them only:
  • "in conjunction with a specialist in dysphagia management; 
  • to investigate the nature and causes of aspiration; 
  • to direct an active treatment/rehabilitation [program] for swallowing difficulties" (p. 86). 

Keywords: Endoscopy, Fluoroscopy, Provider (SLP/Caregiver), Provider, Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

"People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to [maximize] articulation of key words to improve speech intelligibility" (p. 67). 

Keywords: Apraxia

Assessment, treatment, and education materials for the individual with post-stroke aphasia should be provided in his/her preferred language. 

Keywords: Bilingual Considerations, Aphasia, Bilingual Considerations, Education/Training, Education/Counseling

If an individual's speech is unclear or unintelligible post-stroke, he/she should receive evaluation from a speech-language pathologist. Education should be provided as needed to the individual, his/her family/caregivers, and multidisciplinary team as to the impairment and its impact. If speech is unintelligible, the individual should be evaluated for augmentative and alternative communication. 

Keywords: Provider, Provider, Age, Diagnosis/Condition, Adults, Education/Training, Dysarthria, Dysarthria

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

Individuals with post-stroke communication difficulty should be evaluated by a speech-language pathologist. As needed, education should be provided to the individual, his/her family/caregivers, and the multidisciplinary team on the impairment and its impact. The individual should be evaluated for assistive devices as needed by "an appropriately trained, experienced clinician" (p. 65).  Reassessment should only occur within the first four months if needed for decision-making or assessment of mental capacity. 

Keywords: Stroke, Age, Provider, Timing, Aphasia, Adults, Education/Training

Memory assessment is recommended for individuals who clinically demonstrate difficulty learning and remembering, or report memory problems. Assessment should be completed with a standardized measure.

Keywords: Cognitive Assessments (e.g. Metacognitive/Memory/Attention Tests), Cognitive/Linguistic Deficits

Evaluation with a standardized tool is warranted for attention if an individual appears "easily distracted or unable to concentrate" (p. 61). 

Keywords: Cognitive Assessments (e.g. Metacognitive/Memory/Attention Tests), Cognitive/Linguistic Deficits

In regards to cognitive screening and assessment after stroke,
  • "People with stroke should be considered to have at least some cognitive impairment in the early phase. Routine screening should be undertaken to identify the person’s level of functioning, using [standardized] measures" (p. 59).
  • Individuals who are not making expected progress in rehabilitation should receive cognitive assessment to determine whether cognitive impairments are a factor. Results should be shared with the individual, family, and multidisciplinary team.
  • Individuals with communication impairments "should receive a cognitive assessment using valid assessments in conjunction with a speech and language therapist. Specialist advice should be sought if there is uncertainty about the interpretation of cognitive test results" (p. 59). 
  • Safety risks associated with cognitive impairments should be assessed when individuals with acute cognitive impairment transfer care, including potential effects on decision-making. Results should be shared with the primary care team.
  • Full cognitive assessment is recommended for individuals returning to driving or work. 
  • Severe or persistent post-stroke cognitive impairments "should receive specialist assessment and treatment from a clinical neuropsychologist/clinical psychologist" (p. 59). 

Keywords: Cognitive/Linguistic Deficits

Individuals post-stroke who wish to work should receive assessment for cognitive and linguistic potential for return to work. 

Keywords: Cognitive/Linguistic Deficits

Individuals with dysphagia after acute stroke should receive a comprehensive, specialist assessment of swallowing. 

Keywords: Provider (SLP/Caregiver), Setting, Provider, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

"End-of-life (palliative) care for people with stroke should include an explicit decision not to impose burdensome restrictions that may exacerbate suffering. In particular, this may involve a decision, taken together with the person with stroke, those close to them and/or a palliative care specialist, to allow oral food and/or fluids despite a risk of aspiration" (p. 30).

Keywords: Dysphagia, Stroke

The admission pathway of acute stroke services should include, among other services, management protocols for rehabilitation and swallowing assessment. 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Stroke

Treatment

"People with swallowing difficulty after stroke should be provided with written guidance for all staff/carers to use when feeding or providing fluids" (p. 86). 

Keywords: Education/Training, Education/Training (Includes Oral Hygiene), Education/Training (includes Oral Hygiene), Dysphagia, Stroke

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke receiving end-of-life (palliative) care should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering" (p. 71). 

Keywords: Diet Modification, Diet Modification, Dysphagia, Stroke

Individuals experiencing severe difficulty with post-stroke apraxia of speech, "but good cognitive and language function ... should be assessed and provided with alternative or augmentative communication techniques or aids to supplement or compensate for limited speech" (p. 67).  

Keywords: Age, AAC Treatments, AAC Assessments, Apraxia, Adults, Augmentative and Alternative Communication (AAC), Apraxia of Speech

"People with marked difficulty articulating words after stroke should be assessed for apraxia of speech and treated to [maximize] articulation of key words to improve speech intelligibility" (p. 67). 

Keywords: Apraxia

Assessment, treatment, and education materials for the individual with post-stroke aphasia should be provided in his/her preferred language. 

Keywords: Bilingual Considerations, Aphasia, Bilingual Considerations, Education/Training, Education/Counseling

Individuals with post-stroke dysarthria should "be trained in techniques to improve the clarity of their speech" (p. 66), and their communication partners should receive training in assisting with communication. 

Keywords: Education/Training, Dysarthria

Education for communication partners should be provided by a speech-pathologist in order to promote the person with aphasia's participation in rehabilitation and the community. Communication partners include caregivers, family, and "health and social care staff" (p. 66).  

Keywords: Stroke, Provider, Provider, Aphasia, Education/Training, Education/Counseling

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

Individuals with with unilateral impaired awareness should:
  • "Have the impairment explained to them, their family/carers and the multidisciplinary team; 
  • be trained in compensatory strategies to reduce the impact on their activities; 
  • be given cues to draw attention to the affected side during therapy and nursing activities;
  • be monitored to ensure that they do not eat too little through missing food on one side of the plate; 
  • be offered interventions aimed at reducing the functional impact of the reduced awareness" (p. 64), such as visual scanning training, and ideally through a clinical trial. 

Keywords: Visuospatial Treatments (e.g. Visual Scanning), Education/Training, Cognitive/Linguistic Deficits

Individuals post-stroke with identified memory impairments affecting rehabilitation or activities should:
  • be assessed for relative cognitive strengths and weaknesses;
  • receive training in compensatory external techniques (e.g., notebooks, calendars, alarms) or internal strategies for encoding, storing and recalling information;
  • receive treatment in an environment as similar as possible to his/her typical environment, with therapy sessions adjusted as needed to take advantage of preserved ability, and
  • "have the impairment explained to them, their family/carers and the multidisciplinary team" (p. 62). 

Keywords: Environmental Modifications, External Memory Strategies (e.g. PDAs), Internal Memory Strategies (e.g. Mnemonics), Education/Training, Cognitive/Linguistic Deficits

Individuals with executive functioning impairment post-stroke, and their family/caregivers, should receive education on the impairment and its impact. Impact on the individual's function should also be shared with the multidisciplinary team. 

Keywords: Executive Function Treatments (e.g. Metacognitive/Self-Regulation), Education/Training, Cognitive/Linguistic Deficits

Individuals with executive functioning impairment with activity limitation after stroke should receive training in compensatory strategies such as:
  • "Internal strategies (e.g. self-awareness and goal setting), 
  • Structured feedback on performance of functional tasks and
  • External strategies (e.g. use of electronic reminders or written checklists)" (p. 61). 

Keywords: Executive Function Treatments (e.g. Metacognitive/Self-Regulation), Cognitive/Linguistic Deficits

Individuals with attention impairments post-stroke should:
  • "have the impairment explained to them, their family/carers and the multidisciplinary team;
  • be offered an attentional intervention (e.g. time pressure management, attention process training, environmental manipulation), ideally in the context of a clinical trial" (p. 61);
  • receive plenty of opportunity for supported (supervised) practice of their activities. 

Keywords: Attention Treatments (e.g. Attention Processing Training), Environmental Modifications, Cognitive/Linguistic Deficits

"People with continuing cognitive difficulties after stroke should be considered for comprehensive interventions aimed at developing compensatory [behaviors] and learning adaptive skills" (p. 59). 

Keywords: Cognitive/Linguistic Deficits

"Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration" (p. 49). When lying or sitting down, these individuals "should be positioned to [minimize] the risk of aspiration" (p. 50). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

"End-of-life (palliative) care for people with stroke should include an explicit decision not to impose burdensome restrictions that may exacerbate suffering. In particular, this may involve a decision, taken together with the person with stroke, those close to them and/or a palliative care specialist, to allow oral food and/or fluids despite a risk of aspiration" (p. 30).

Keywords: Dysphagia, Stroke

The admission pathway of acute stroke services should include, among other services, management protocols for rehabilitation and swallowing assessment. 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Stroke

Service Delivery

Patients with impaired swallowing following stroke should be considered for a specialist rehabilitation program. Treatment should include one or more of the following:
  • "compensatory strategies such as postural changes (e.g. chin tuck) or swallowing [maneuvers] (e.g. supraglottic swallow)" (p. 86);
  • strategies to improve oral motor function (e.g., Shaker exercises);
  • modification of sensory properties of the bolus (e.g., taste, temperature, carbonation);
  • diet modification according to nationally agreed descriptors. 
If an impairment remains upon discharge, the individual and family/caregivers should be trained to manage the impairment, with reassessment as needed.

Keywords: Provider, Provider (SLP/Caregiver), Diet Modification, Education/Training, Diet Modification, Education/Training (includes Oral Hygiene), Dysphagia, Oral-Motor Treatments, Postural Techniques/Maneuvers, Thermal/Tactile Stimulation, Oral Motor Treatments (includes Shaker Exercises), Postural Techniques/Maneuvers, Sensory Stimulation, Stroke

"People with stroke with suspected aspiration or who require tube feeding or dietary modification should be considered for instrumental assessment (videofluoroscopy or [fiberoptic] endoscopic evaluation of swallowing)" (p. 86). Individuals who require these assessments should receive them only:
  • "in conjunction with a specialist in dysphagia management; 
  • to investigate the nature and causes of aspiration; 
  • to direct an active treatment/rehabilitation [program] for swallowing difficulties" (p. 86). 

Keywords: Endoscopy, Fluoroscopy, Provider (SLP/Caregiver), Provider, Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

If an individual's speech is unclear or unintelligible post-stroke, he/she should receive evaluation from a speech-language pathologist. Education should be provided as needed to the individual, his/her family/caregivers, and multidisciplinary team as to the impairment and its impact. If speech is unintelligible, the individual should be evaluated for augmentative and alternative communication. 

Keywords: Provider, Provider, Age, Diagnosis/Condition, Adults, Education/Training, Dysarthria, Dysarthria

Education for communication partners should be provided by a speech-pathologist in order to promote the person with aphasia's participation in rehabilitation and the community. Communication partners include caregivers, family, and "health and social care staff" (p. 66).  

Keywords: Stroke, Provider, Provider, Aphasia, Education/Training, Education/Counseling

Within the first four months post-stroke, individuals with aphasia should receive frequent practice with a speech-language pathologist or communication partner. After four months, as determined by reassessment, the person with aphasia may participate in further treatment, which "may involve using an assistant or volunteer, family member or communication partner guided by the speech and language therapist, computer-based practice or other impairment-based or functional treatment" (p. 65). At this time, treatment should focus on increasing participation. 

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Provider, Timing, Dosage (e.g. Frequency/Intensity), Provider, Timing, Aphasia

Individuals with post-stroke communication difficulty should be evaluated by a speech-language pathologist. As needed, education should be provided to the individual, his/her family/caregivers, and the multidisciplinary team on the impairment and its impact. The individual should be evaluated for assistive devices as needed by "an appropriately trained, experienced clinician" (p. 65).  Reassessment should only occur within the first four months if needed for decision-making or assessment of mental capacity. 

Keywords: Stroke, Age, Provider, Timing, Aphasia, Adults, Education/Training

"Patients with swallowing difficulties after acute stroke should only be given food, fluids and medications in a form that can be swallowed without aspiration" (p. 49). When lying or sitting down, these individuals "should be positioned to [minimize] the risk of aspiration" (p. 50). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals with dysphagia after acute stroke should receive a comprehensive, specialist assessment of swallowing. 

Keywords: Provider (SLP/Caregiver), Setting, Provider, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals with residual neurological symptoms or signs of acute stroke or transient ischemic attack (TIA) should be NPO (nil per os/nothing by mouth) until they have received dysphagia screening from "a specifically trained healthcare professional" (p. 35). 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Dysphagia, Stroke

Individuals should be screened for cognitive impairment through observation and validated tools. Screens should occur at the following time periods:
  • "Within six weeks of stroke (in the acute phase of rehabilitation and at the transfer of care into post-acute services)" (p. 27);
  • At six months; and
  • At 12 months. 

Keywords: Timing, Cognitive/Linguistic Deficits

Stroke rehabilitation units and early supported discharge teams should have a multidisciplinary team including specialists in speech-language pathology.

Keywords: Provider

The admission pathway of acute stroke services should include, among other services, management protocols for rehabilitation and swallowing assessment. 

Keywords: Setting, Setting (e.g. Acute/Outpatient), Stroke

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