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

New Zealand Ministry of Health
 
New Zealand Clinical Guidelines for Stroke Management 2010
Stroke Foundation of New Zealand and New Zealand Guidelines Group (2010).
Wellington (New Zealand): Stroke Foundation of New Zealand, 347 pages.
 
AGREE Rating: Highly Recommended

Description:
This guideline provides recommendations for the management of individuals recovering from stroke and transient ischemic attacks. The target audience of the guideline is all healthcare professionals providing services to persons with stroke and their family in the New Zealand context. Of particular interest to speech-language pathologists are the sections discussing communication (aphasia, apraxia, dysarthria), cognition and swallowing disorders. Levels of evidence recommendations are graded as A, B, C, D or "Good Practice Points" and defined as follows:

  • Level A: Body of evidence can be trusted to guide practice.
  • Level B: Body of evidence can be trusted to guide practice in most situations.
  • Level C: Body of evidence provides some support for recommendation(s) but care should be taken in its application.
  • Level D: Body of evidence is weak and recommendation must be applied with caution.
  • Good Practice Point: Recommended best practice based on clinical experience and expert opinion.

Recommendations:

  • Assessment/Diagnosis
    • Screening
      • All patients with suspected aphasia should be screened for communication deficits using a valid and reliable screening tool (Level C Evidence).
    • Comprehensive Assessment
      • Individuals with aphasia should receive a comprehensive assessment by a specialized clinician (Good Practice Point).
      • The nature and extent of aphasia should be documented and discussed with the patient and family (Good Practice Point).
      • In collaboration with the patient and carer, individualized goals and treatment plan should be developed and reassessed at appropriate intervals (Good Practice Point). 
    • Assessment Areas
      • General Findings
        • All patients with suspected aphasia should be screened for communication deficits using a valid and reliable screening tool (Level C Evidence).
        • Individuals with aphasia should receive a comprehensive assessment by a specialized clinician (Good Practice Point).
        • The nature and extent of aphasia should be documented and discussed with the patient and family (Good Practice Point).
        • In collaboration with the patient and carer, individualized goals and treatment plan should be developed and reassessed at appropriate intervals (Good Practice Point).
      • Cognition - All patients should be screed for cognitive problems using a valid and reliable screening tool (Good Practice Point).
      • Swallowing - All patients should be screened for swallowing problems within 24 hours of admission (Good Practice Point).
      • Speech - Patients with unintelligible speech or motor speech difficulties should be assessed to determine the nature and cause of the speech impairment (Good Practice Point).
    • Assessment Instruments
      • Swallowing
        • General Findings - The gag reflex is not a valid screen for dysphagia and should NOT be used as a screening tool (Level B Evidence).
        • Instrumental Examination - Comprehensive swallowing assessment by speech-language pathologist may include instrumental examination (e.g., video fluoroscopic and/or fiberoptic endoscopic evaluation of swallowing (Good Practice Point).
  • Treatment
    • Cognition
      • General Findings
        • Cognitive rehabilitation can be given to individuals with impairments in attention and concentration (Level C Evidence).
        • Cognitive rehabilitation using external cues, such as a pager, can be used to assist individuals with impaired executive functioning (Level C Evidence). 
      • Compensatory Memory Treatment - Compensatory strategies can be used for individuals with memory problems and may include the use of notebooks, diaries, and electronic aids (Level D Evidence).
      • Neglect - Individuals with neglect may benefit from interventions that draw to draw attention to the affected side (Good Practice Point); visual scanning training (Level C Evidence); mental imagery training (Level D Evidence); structured feedback (Level D Evidence).
    • Speech
      • Apraxia
        • Motor speech interventions can target articulatory placement and transitioning, speech rate and rhythm, increasing length and complexity of words and sentences, prosody including lexical, phrasal, and contrastive stress production (Level D Evidence).
        • Specific treatments may incorporate stimulation, structure practice sessions, PROMPT, and use of AAC or multi-modal communication (Level D Evidence).
      • Dysarthria
        • Interventions to improve speech intelligibility may include biofeedback (D), LSVT (Level D Evidence), AAC (Good Practice Point) or the use of strategies such as decreased rate, over-articulation or gesture (Good Practice Point).
    • Language
      • Augmentative and Alternative Communication (AAC) - For individuals with aphasia, the use of alternate means of communication (AAC, gestures, drawing) should be considered (Good Practice Point).  
      • Constraint-Induced Language Therapy (CILT) - The use of constraint-induced language therapy is recommended for individuals with aphasia (Level B Evidence).  
      • Computer-Based Treatment - The use of computer-based treatment is recommended for individuals with aphasia (Level C Evidence).
      • Conversation Partner Training Approaches
        • Supported conversation techniques are recommended for individuals with aphasia (Level C Evidence).
        • Conversation partner training should address environmental barriers of individuals with aphasia and promote access and inclusion through aphasia-friendly formats and other environmental adaptions (Good Practice Point). 
      • Multi-Modal Treatment - The use of gestures is recommended for individuals with aphasia (Level D Evidence).  Alternate means of communication should include gestures, drawing, writing and AAC (Good Practice Point). 
      • Language-Oriented Therapy - For individuals with aphasia, treatment targeting specific aspects of language should be considered (e.g. phonological and semantic deficits, reading, writing, sentence comprehension) based on models derived from cognitive neuropsychology (Level C Evidence).
    • Swallowing
      • Compensatory Treatments - Recommend use of compensatory strategies such as positioning, therapeutic postures or maneuvers or diet modification to facilitate safe swallowing (Level B Evidence).
      • Oral Motor Treatment - Swallowing treatments may include treatments targeting specific muscle groups (e.g. Shaker exercise) or thermal tactile stimulation (Level C Evidence).
  • Service Delivery
    • Dosage
      • Treatment for swallowing should be provided as much as can be tolerated (Level C Evidence).
    • Bilingual Considerations
      • Interpreters should be considered for individuals with aphasia with culturally and linguistically diverse backgrounds (Good Practice Point).
    • Format
      • Group treatment and conversation groups are recommended for individuals with aphasia (Level C Evidence).
      • For individuals with chronic aphasia, group treatment should be recommended for longer durations (Level C Evidence).
    • Timing
      • Aphasia treatment should be initiated as early as possible and as can be tolerated (Level B Evidence).  

Keywords:
Stroke, Aphasia

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