Summary of the Clinical Practice Guideline

Article Citation

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Winstein, C. J., Stein, J., et al. (2016).
Stroke, 47, e98-e169.
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Sponsoring Body

American Heart Association; American Stroke Association

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Article Details

Description

This guideline provides recommendations for the rehabilitation of adults recovering from a stroke. The target audience includes all relevant professionals involved in the rehabilitation management of stroke patients, which includes speech-language pathologists and audiologists. Of particular interest to clinicians are the recommendations for the assessment of communication, cognition, swallowing, and hearing. Recommendations for management options are also presented.

Evidence Ratings for This Document

Recommendations were graded based on the American Heart Association and American Stroke Association's classification system, as follows:

  • Level A Recommendation: Treatment recommendation(s) are derived from multiple randomized controlled trials or meta-analyses. Assessment recommendation(s) are derived from multiple prospective cohort studies that used a reference standard applied by a blinded evaluator.
  • Level B Recommendation: Treatment recommendation(s) are derived from one randomized controlled study or multiple nonrandomized controlled studies. Assessment recommendation(s) are derived from one Level A study, more than one case-control study, or are derived from studies that used a reference standard applied by a blinded evaluator.
  • Level C Recommendation: Treatment or assessment recommendation(s) are derived from consensus expert opinion, case studies, or standard of care.

The classes of evidence that support the recommendations are defined as follows: 

  • Class I Evidence: General agreement for; evidence shows that the treatment(s) or assessment(s) are useful and effective.
  • Class II Evidence: Differing opinion; conflicting evidence exists as to the usefulness and effectiveness of the treatment(s) or assessment(s).
    • Class IIa: The weight of the evidence is in favor of the usefulness/efficacy of the treatment or assessment.
    • Class IIb: The weight of the evidence is less established regarding usefulness/efficacy of the treatment or assessment.
  • Class III Evidence: General agreement against; evidence shows that the treatment(s) or assessment(s) are NOT useful or effective and may be harmful.

Recommendations from This Guideline

What are Recommendations?

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Treatment

For individuals with stroke-induced aphasia, computer-based treatment may be included as a supplement to speech and language treatment (Level A Recommendation, Class IIb Evidence).

Keywords: Stroke, Computer-Based Treatments, Aphasia, Computer-Based Treatments

For individuals with stroke-induced aphasia, communication partner training should be included as part of treatment (Level B Recommendation, Class I Evidence).

Keywords: Stroke, Supported Communication Treatments (e.g. Conversation Partner Training), Aphasia, Conversation Partner Training

For individuals with stroke-induced aphasia, speech and language therapy is recommended (Level A Recommendation, Class I Evidence).

Keywords: Stroke, Aphasia

Service Delivery

While there are no recommendations for the exact frequency, intensity, timing, format or duration of treatment, the guideline indicates that intensive treatment (Level A Recommendation, IIa Evidence) and group treatment (Level B Recommendation, IIb Evidence) may be warranted for individuals with stroke-induced aphasia.

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Aphasia

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Treatment

For individuals with dysarthria or apraxia of speech, "activities to facilitate social participation and promote psychosocial well-being may be considered" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

For individuals with dysarthria or apraxia of speech secondary to a stroke, "environmental modifications, including listener education, may be considered to improve communication effectiveness" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Speech Treatments (e.g. LSVT/Pacing Strategies/Voice Amplifier), Acquired Brain Injury, Apraxia, Dysarthria, Environmental Modifications

For individuals with dysarthria or apraxia of speech secondary to a stroke, "augmentative and alternative communication devices and modalities should be used to supplement speech" (Level C Recommendation, Class I Evidence; p. e125).

Keywords: Age, Diagnosis/Condition, AAC Treatments, Acquired Brain Injury, Acquired Brain Injury, Adults, Augmentative and Alternative Communication (AAC), Apraxia, Augmentative and Alternative Communication (AAC), Dysarthria

"Interventions for motor speech disorders [i.e., dysarthria and apraxia of speech] should be individually tailored and can include behavioral techniques and strategies that target

  • physiological support for speech, including respiration, phonation, articulation, and resonance; and
  • global aspects of speech production such as loudness, rate, and prosody" (Level B Recommendation, Class I Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

Service Delivery

For individuals with dysarthria or apraxia of speech, "telerehabilitation may be useful when face-to-face treatment is impossible or impractical" (Level C Recommendation, Class IIa Evidence; p. e125).

Keywords: Format (Group/Telepractice), Format (e.g. Group/Telepractice), Format (e.g. Group/Telepractice), Acquired Brain Injury, Apraxia, Dysarthria

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Treatment

For individuals with dysarthria or apraxia of speech secondary to a stroke, "augmentative and alternative communication devices and modalities should be used to supplement speech" (Level C Recommendation, Class I Evidence; p. e125).

Keywords: Age, Diagnosis/Condition, AAC Treatments, Acquired Brain Injury, Acquired Brain Injury, Adults, Augmentative and Alternative Communication (AAC), Apraxia, Augmentative and Alternative Communication (AAC), Dysarthria

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Assessment

"Individuals with stroke should be evaluated for balance, balance confidence, and fall risk" (Level C Recommendation, Class I Evidence; p. e127).

Keywords: Comorbid Disorders and Diseases, Acquired Brain Injuries (e.g. Concussion/Stroke), Hearing Loss/Balance Disorders

Go to Map

Treatment

For individuals with dysarthria or apraxia of speech, "activities to facilitate social participation and promote psychosocial well-being may be considered" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

For individuals with dysarthria or apraxia of speech secondary to a stroke, "environmental modifications, including listener education, may be considered to improve communication effectiveness" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Speech Treatments (e.g. LSVT/Pacing Strategies/Voice Amplifier), Acquired Brain Injury, Apraxia, Dysarthria, Environmental Modifications

For individuals with dysarthria or apraxia of speech secondary to a stroke, "augmentative and alternative communication devices and modalities should be used to supplement speech" (Level C Recommendation, Class I Evidence; p. e125).

Keywords: Age, Diagnosis/Condition, AAC Treatments, Acquired Brain Injury, Acquired Brain Injury, Adults, Augmentative and Alternative Communication (AAC), Apraxia, Augmentative and Alternative Communication (AAC), Dysarthria

"Interventions for motor speech disorders [i.e., dysarthria and apraxia of speech] should be individually tailored and can include behavioral techniques and strategies that target

  • physiological support for speech, including respiration, phonation, articulation, and resonance; and
  • global aspects of speech production such as loudness, rate, and prosody" (Level B Recommendation, Class I Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

Service Delivery

For individuals with dysarthria or apraxia of speech, "telerehabilitation may be useful when face-to-face treatment is impossible or impractical" (Level C Recommendation, Class IIa Evidence; p. e125).

Keywords: Format (Group/Telepractice), Format (e.g. Group/Telepractice), Format (e.g. Group/Telepractice), Acquired Brain Injury, Apraxia, Dysarthria

Go to Map

Screening

Early dysphagia screening is recommended for adults with acute stroke (Level B Recommendation, Class I Evidence). Dysphagia screening should be completed by a speech-language pathologist or another healthcare professional trained in dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Provider (SLP/Caregiver), Provider, Dysphagia, Stroke

Assessment

Recommendations for the type of instrumental swallowing evaluation (i.e., use of videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, or fiberoptic endoscopic evaluation of swallowing with sensory testing) should be determined based on availability and other patient considerations (Level C Recommendation, Class IIb Evidence).

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

Instrumental evaluation of swallowing is recommended for stroke patients with suspected dysphagia to confirm presence/absence of aspiration, find the physiological reasons for dysphagia, and assist with establishing a treatment plan (Level B Recommendation, Class I Evidence).

Keywords: Imaging Assessment (Not Specified), Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

Swallowing assessment is recommended prior to oral intake (Level B Recommendation, Class I Evidence).

Keywords: Dysphagia, Stroke

Treatment

The benefits of neuromuscular electrical stimulation or pharyngeal electrical stimulation are uncertain. Therefore, this treatment is currently not recommended for adults with stroke-induced dysphagia (Level A Recommendation, Class III Evidence).

Keywords: Electrical Stimulation, Electrical Stimulation, Dysphagia, Stroke

Swallowing treatment should incorporate the principles of neuroplasticity for adults with stroke-induced dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Dysphagia, Stroke

Behavioral swallowing interventions are recommended as a component of treatment for adults with stroke-induced dysphagia (Level A Recommendation, Class IIb Evidence).

Keywords: Dysphagia, Stroke

Oral hygiene protocols are recommended for patients with dysphagia to reduce the risk of aspiration pneumonia post stroke (Level B Recommendation, Class I Evidence).

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

Service Delivery

Early dysphagia screening is recommended for adults with acute stroke (Level B Recommendation, Class I Evidence). Dysphagia screening should be completed by a speech-language pathologist or another healthcare professional trained in dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Provider (SLP/Caregiver), Provider, Dysphagia, Stroke

Go to Map

Assessment

"If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Provider, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Provider, Hearing Loss/Balance Disorders

"Evaluation of stroke patients for sensory impairments, including touch, vision, and hearing, is probably indicated (Level B Recommendation, Class IIb Evidence; p. e118).

Keywords: Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Hearing Loss/Balance Disorders

Treatment

For stroke patients with hearing loss, "it is reasonable to use communication strategies such as looking at the patient when speaking" (Level C Recommendation, Class IIa Evidence; p. e136) and "it is reasonable to minimize the level of background noise in the patient’s environment" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Speech Treatments (e.g. LSVT/Pacing Strategies/Voice Amplifier), Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Compensatory Strategies, Environmental Modifications, Hearing Loss/Balance Disorders, Aural Rehabilitation

For stroke patients with hearing loss, "it is reasonable to use some form of amplification (e.g., hearing aids)" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Amplification (e.g. Hearing Aids/Voice Amplifiers/Environmental Modifications), Hearing Aids, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Hearing Loss/Balance Disorders, Devices

Service Delivery

"If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Provider, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Provider, Hearing Loss/Balance Disorders

Go to Map

Screening

Early dysphagia screening is recommended for adults with acute stroke (Level B Recommendation, Class I Evidence). Dysphagia screening should be completed by a speech-language pathologist or another healthcare professional trained in dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Provider (SLP/Caregiver), Provider, Dysphagia, Stroke

Assessment

"If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Provider, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Provider, Hearing Loss/Balance Disorders

"Evaluation of stroke patients for sensory impairments, including touch, vision, and hearing, is probably indicated (Level B Recommendation, Class IIb Evidence; p. e118).

Keywords: Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Hearing Loss/Balance Disorders

"Individuals with stroke should be evaluated for balance, balance confidence, and fall risk" (Level C Recommendation, Class I Evidence; p. e127).

Keywords: Comorbid Disorders and Diseases, Acquired Brain Injuries (e.g. Concussion/Stroke), Hearing Loss/Balance Disorders

Recommendations for the type of instrumental swallowing evaluation (i.e., use of videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, or fiberoptic endoscopic evaluation of swallowing with sensory testing) should be determined based on availability and other patient considerations (Level C Recommendation, Class IIb Evidence).

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

Instrumental evaluation of swallowing is recommended for stroke patients with suspected dysphagia to confirm presence/absence of aspiration, find the physiological reasons for dysphagia, and assist with establishing a treatment plan (Level B Recommendation, Class I Evidence).

Keywords: Imaging Assessment (Not Specified), Swallowing Assessments-Imaging (e.g. FEES/VFSS), Dysphagia, Stroke

Swallowing assessment is recommended prior to oral intake (Level B Recommendation, Class I Evidence).

Keywords: Dysphagia, Stroke

Treatment

While there are no recommendations for the exact frequency, intensity, timing, format or duration of treatment, the guideline indicates that intensive treatment (Level A Recommendation, IIa Evidence) and group treatment (Level B Recommendation, IIb Evidence) may be warranted for individuals with stroke-induced aphasia.

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Aphasia

For individuals with stroke-induced aphasia, computer-based treatment may be included as a supplement to speech and language treatment (Level A Recommendation, Class IIb Evidence).

Keywords: Stroke, Computer-Based Treatments, Aphasia, Computer-Based Treatments

For individuals with stroke-induced aphasia, communication partner training should be included as part of treatment (Level B Recommendation, Class I Evidence).

Keywords: Stroke, Supported Communication Treatments (e.g. Conversation Partner Training), Aphasia, Conversation Partner Training

For individuals with stroke-induced aphasia, speech and language therapy is recommended (Level A Recommendation, Class I Evidence).

Keywords: Stroke, Aphasia

For stroke patients with hearing loss, "it is reasonable to use communication strategies such as looking at the patient when speaking" (Level C Recommendation, Class IIa Evidence; p. e136) and "it is reasonable to minimize the level of background noise in the patient’s environment" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Speech Treatments (e.g. LSVT/Pacing Strategies/Voice Amplifier), Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Compensatory Strategies, Environmental Modifications, Hearing Loss/Balance Disorders, Aural Rehabilitation

For stroke patients with hearing loss, "it is reasonable to use some form of amplification (e.g., hearing aids)" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Amplification (e.g. Hearing Aids/Voice Amplifiers/Environmental Modifications), Hearing Aids, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Hearing Loss/Balance Disorders, Devices

For individuals with dysarthria or apraxia of speech, "activities to facilitate social participation and promote psychosocial well-being may be considered" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

For individuals with dysarthria or apraxia of speech secondary to a stroke, "environmental modifications, including listener education, may be considered to improve communication effectiveness" (Level C Recommendation, Class IIb Evidence; p. e125).

Keywords: Speech Treatments (e.g. LSVT/Pacing Strategies/Voice Amplifier), Acquired Brain Injury, Apraxia, Dysarthria, Environmental Modifications

For individuals with dysarthria or apraxia of speech, "telerehabilitation may be useful when face-to-face treatment is impossible or impractical" (Level C Recommendation, Class IIa Evidence; p. e125).

Keywords: Format (Group/Telepractice), Format (e.g. Group/Telepractice), Format (e.g. Group/Telepractice), Acquired Brain Injury, Apraxia, Dysarthria

For individuals with dysarthria or apraxia of speech secondary to a stroke, "augmentative and alternative communication devices and modalities should be used to supplement speech" (Level C Recommendation, Class I Evidence; p. e125).

Keywords: Age, Diagnosis/Condition, AAC Treatments, Acquired Brain Injury, Acquired Brain Injury, Adults, Augmentative and Alternative Communication (AAC), Apraxia, Augmentative and Alternative Communication (AAC), Dysarthria

"Interventions for motor speech disorders [i.e., dysarthria and apraxia of speech] should be individually tailored and can include behavioral techniques and strategies that target

  • physiological support for speech, including respiration, phonation, articulation, and resonance; and
  • global aspects of speech production such as loudness, rate, and prosody" (Level B Recommendation, Class I Evidence; p. e125).

Keywords: Acquired Brain Injury, Apraxia, Dysarthria

The benefits of neuromuscular electrical stimulation or pharyngeal electrical stimulation are uncertain. Therefore, this treatment is currently not recommended for adults with stroke-induced dysphagia (Level A Recommendation, Class III Evidence).

Keywords: Electrical Stimulation, Electrical Stimulation, Dysphagia, Stroke

Swallowing treatment should incorporate the principles of neuroplasticity for adults with stroke-induced dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Dysphagia, Stroke

Behavioral swallowing interventions are recommended as a component of treatment for adults with stroke-induced dysphagia (Level A Recommendation, Class IIb Evidence).

Keywords: Dysphagia, Stroke

Oral hygiene protocols are recommended for patients with dysphagia to reduce the risk of aspiration pneumonia post stroke (Level B Recommendation, Class I Evidence).

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

Service Delivery

While there are no recommendations for the exact frequency, intensity, timing, format or duration of treatment, the guideline indicates that intensive treatment (Level A Recommendation, IIa Evidence) and group treatment (Level B Recommendation, IIb Evidence) may be warranted for individuals with stroke-induced aphasia.

Keywords: Stroke, Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Dosage (e.g. Frequency/Intensity), Format (e.g. Group/Telepractice), Aphasia

"If a patient is suspected of a hearing impairment, it is reasonable to refer to an audiologist for audiometric testing" (Level C Recommendation, Class IIa Evidence; p. e136).

Keywords: Provider, Comorbid Diseases and Disorders, Acquired Brain Injuries (e.g. Stroke/TBI), Provider, Hearing Loss/Balance Disorders

For individuals with dysarthria or apraxia of speech, "telerehabilitation may be useful when face-to-face treatment is impossible or impractical" (Level C Recommendation, Class IIa Evidence; p. e125).

Keywords: Format (Group/Telepractice), Format (e.g. Group/Telepractice), Format (e.g. Group/Telepractice), Acquired Brain Injury, Apraxia, Dysarthria

Early dysphagia screening is recommended for adults with acute stroke (Level B Recommendation, Class I Evidence). Dysphagia screening should be completed by a speech-language pathologist or another healthcare professional trained in dysphagia (Level C Recommendation, Class IIa Evidence).

Keywords: Provider (SLP/Caregiver), Provider, Dysphagia, Stroke

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