The National Center for Evidence-Based Practice
in Communication Disorders
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Summary of Clinical Practice Guideline

Catalan Agency for Health Technology Assessment and Research
 
Stroke: Clinical Practice Guideline (2nd edition)
Catalan Agency for Health Technology Assessment and Research. (2007).
Barcelona (Spain): Catalan Agency for Health Technology Assessment and Research, 112 pages.
 
AGREE Rating: Highly Recommended

Description:
This guideline provides recommendations for the assessment, management, and rehabilitation of acute stroke in adults. The target audiences for this guideline include professionals, managers, and planners involved in the care of adults with acute stroke. Of particular interest to speech-language pathologists is the section on assessment and intervention for aphasia, dysarthria, cognitive disorders and dysphagia. Recommendations are graded A, B, C, D, or "Point of Good Practice" based on the strength of supporting evidence below:  

  • Grade A: Recommendations based on evidence from systematic reviews and meta-analyses of randomized controlled trials that are directly relevant to the population.
  • Grade B: Recommendations based on high quality case control or cohort studies or high quality systematic reviews of those studies that are directly applicable to the population, or recommendations extrapolated from Grade A evidence.
  • Grade C: Recommendations based on well conducted case control or cohort studies or recommendations extrapolated from Grade B evidence.
  • Grade D: Recommendations based on evidence from non-analytic studies or expert opinion or recommendations extrapolated from Grade C evidence.
  • Points of Good Practice: Recommendations based on the clinical experience of the guideline development group.

Recommendations:

  • Assessment/Diagnosis
    • Comprehensive Assessment
      • Patients with left hemisphere damage should be evaluated for aphasia by a speech-language pathologist using valid and reliable methods (Grade C Evidence).  Individuals with aphasia should receive treatment and periodic assessments as long as there are identifiable objectives and progress (Grade B Evidence).
    • Assessment Areas
      • Speech - “Patients with dysarthria must be referred to a speech and language therapist for assessment and guidance. The specialist will make the differential diagnosis and will carry out the treatment, and will determine the time and type of intervention, as well as the needs for amplification and alternative communication systems” (Point of Good Practice) (p. 68).
      • Swallowing - “If there is suspicion of dysphagia and/or risk of pulmonary aspiration, the patient must be evaluated by a trained specialist who will determine the conditions for safe swallowing, as well as the consistency of the solid and liquid diet” (Grade A Evidence) (p. 56).
    • Assessment Instruments
      • Bedside Swallow Exam - “The assessment of dysphagia must be made as soon as possible, preferably in the course of admission, with a simple and validated clinical swallowing test. The nausea reflex test is not a valid swallowing test. Current scientific evidence lends greater support to voluntary cough and the sensitive pharynx test” (Grade B Evidence) (p. 56).
      • Videofluoroscopy - “The use of videofluoroscopy must be assessed when alterations are detected in the clinical swallowing test. If the alteration of the pharyngeal phase of swallowing persists, instrumental and dynamic tests must be considered to view the pharynx during the passage of different volumes and consistencies of food” (Grade B Evidence) (p. 56).
  • Treatment
    • Cognition
      • General Findings - “Patients must learn problem-solving strategies and how to apply them in everyday situations and in functional activities in the post acute phase of the rehabilitation” (Grade D Evidence) (p. 69).
      • Compensatory Memory Treatments - "Specific interventions targeting facilitating the learning of compensatory strategies (sound alarms, notebooks, diaries, electronic organizers, etc.) are recommended in patients with memory deficits” (Grade B Evidence) (p. 68).
      • Compensatory Executive Function Treatments - “Patients with alteration of executive functions must be taught compensatory techniques such as the use of electronic organizers or written lists of needs to improve the execution of ADL” (Grade B Evidence) (p. 69).
      • Drill and Practice Attention Training - “Patients with attention disorders must receive treatment targeting the improvement of the level of alertness and the capacity to sustain attention” (Grade B Evidence) (p. 68).
      • Visual Neglect Treatment - “Patients with persistent and disabling neglect/spatial inattention must be treated with specific techniques such as cueing, scanning, limb activation, aids and adaptations of the environment” (Grade B Evidence) (p. 68).
    • Speech
      • Apraxia Treatment - “Patients with apraxia must be instructed in the use of internal and external aids (e.g., verbalization and following written/pictorial action sequences)” (Grade A Evidence) (p. 69).
    • Language
      • General Findings - Individuals with aphasia should receive treatment and periodic assessments as long as there are identifiable objectives and progress (Grade B Evidence).
      • Augmentative and Alternative Communication (AAC): The use of an augmentative and alternative communication device may improve functional communication (Grade B Evidence).
      • Computer-Based Treatment - Computer-based language treatment is efficacious (Grade A Evidence).
  • Service Delivery
    • Dosage
      • Individuals with stroke-induced aphasia may benefit from intensive speech therapy in a short period of time (Grade B Evidence).
      • Evidence suggests that individuals with stroke-induced aphasia receive SLP treatment between two to eight hours a week (Grade B Evidence).
    • Timing
      • Treatment initiated early is more effective than treatment initiated later (Grade A Evidence).
    • Format
      • The incorporation of group treatment is supported (Grade B Evidence).  
    • Provider
      • Aphasia recovery is more significant in patients treated by a speech-language pathologist (Grade B Evidence).
      • Incorporation of trained volunteers as part of treatment is supported (Grade B Evidence).

Keywords:
Stroke, Aphasia

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