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Réadaptation en vue d’améliorer la capacité à parler et à communiquer

2016 MISE À JOUR
février 2016

La 5e édition des Recommandations canadiennes pour les pratiques optimales de soins de l’AVC sur Réadaptation post-AVC (2015) est publiée dans l’International Journal of Stroke et est accessible en ligne gratuitement. Afin d’accéder aux recommandations spécifiques pour : Réadaptation en vue d’améliorer la capacité à parler et à communiquer, et tous les autres chapitres des recommandations sur Réadaptation post-AVC, veuillez cliquer sur ce lien, qui vous dirigera vers les recommandations en ligne dans l’Internal Journal of Stroke : http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

Pour la version française de ces recommandations, veuillez consulter l’annexe en cliquant sur le lien suivant : http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

Tous les autres renseignements connexes, y compris les indicateurs de rendement, les ressources de mise en l’œuvre, les résumés des données probantes et les références, sont accessibles au www.pratiquesoptimales.ca, et non pas sur le site de l’International Journal of Stroke. Veuillez cliquer sur les sections appropriées de notre site Web pour le contenu additionnel.

Justification

L’aphasie est la perte de la capacité de communiquer verbalement, par des signes ou par l’écrit ou de comprendre de telles communications. Elle est l’une des conséquences les plus communes de l’AVC en phase autant aiguë que chronique. On estime que de 21 à 38 % des patients ayant survécu à un AVC sont aphasiques. La présence de l’aphasie a été associée à une réponse globalement moins positive aux interventions de réadaptation et à un risque accru de mortalité. La prise en charge résolue de l’aphasie n’est donc pas seulement bénéfique pour le rétablissement de la communication, mais également pour obtenir un meilleur rétablissement en général.

Exigences pour le système

Les patients qui présentent des déficits en matière de communication, leurs familles et leurs aidants doivent avoir accès à des programmes d’orthophonie post-AVC en milieu hospitalier et communautaire :

  • Des programmes et des services devraient être mis en place à cet effet dans tous les organismes et toutes les collectivités qui offrent des services de soutien aux patients avec AVC qui éprouvent des difficultés de communication, notamment en offrant l’accès aux services d’orthophonistes.
  • La télémédecine devrait être sérieusement prise en compte et activement utilisée, particulièrement dans les régions où il y a peu d’orthophonistes, afin de garantir un accès équitable à des occasions de réadaptation aux patients avec aphasie post-AVC.
  • Des programmes de soutien, notamment par des groupes de pairs, devraient être mis sur pied et les patients informés des moyens pour accéder à ces groupes en milieu de soins tant actifs que de réadaptation.

Indicateurs de rendement

  1. Pourcentage des patients chez lesquels l’aphasie est dépistée à l’admission aux soins actifs et à l’évaluation initiale à l’admission aux soins de réadaptation.
  2. Pourcentage des patients aphasiques qui obtiennent une évaluation approfondie par un orthophoniste avant le congé des soins actifs.
  3. Délai médian entre le congé de l’hôpital et l’amorce de traitements de l’aphasie en milieu communautaire.
  4. Nombre de membres du personnel dans chaque milieu de soins de réadaptation ayant reçu une formation sur les techniques de soutien à la communication.
  5. Pourcentage du temps que chaque patient victime d’AVC présentant des problèmes de communication passe en thérapie avec le spécialiste en communication (un orthophoniste, ou un autre professionnel ayant reçu une formation appropriée s’il n’est pas possible d’avoir accès aux services d’un orthophoniste).

Ressources pour la mise en œuvre et outils d’application des connaissances

Renseignements destinés aux fournisseurs de soins de santé

Renseignements destinés au patient

Résumé des données probantes

Lien vers les tableaux de données probantes et la liste des références

A report based on data from the Ontario Stroke Audit estimated that 35% of individuals with stroke have symptoms of aphasia at the time of discharge from acute care (Dickey et al., 2010). Risk factors for aphasia following stroke include older age and greater severity of stroke and stroke-related disability (Dickey et al., 2010; Bersano et al., 2009; Gialanella & Prometti, 2009; Pedersen et al., 2004; Ferro et al., 1999). Presence of post-stroke aphasia is associated with longer lengths of hospital stay (Gialanella & Prometti, 2009), poorer outcomes in terms of activities of daily living and mobility (Gialanella & Prometti, 2009; Paolucci et al., 2005), discharge to long-term care (Gialanella & Prometti, 2009; Dickey et al., 2010), and higher rates of mortality over both the short and long-term following stroke (Bersano et al., 2009). Additionally, aphasia has been demonstrated to have a negative impact on quality of life, mood, and social outcomes (Davidson et al., 2008; Ferro et al., 1999; Wade et al., 1986).

In general, there is a large literature base examining the effectiveness of speech and language therapy (SLT) for the treatment of aphasia following stroke. In an updated Cochrane review, Brady and colleagues identified 39 RCTs (n=2518) investigating SLT for post-stroke aphasia, 19 (n=1414) of which compared SLT to no treatment (Brady et al., 2012). Patients who received SLT experienced significantly more improvement in functional communication (p<0.01), reading comprehension (p<0.05), and expressive language (p<0.05), as compared to patients randomized to a no treatment control group. An additional 7 trials (n=279) compared SLT to social support/stimulation. Although pooled analysis revealed mixed findings, results from a large (n=170) trial suggests that, as compared to unstructured social contact, SLT may not be associated with significantly greater improvement in functional language ability (Bowen et al. 2012). Additional research from Rose et al. (2013) reports that gesture training combining symbolic gestures with verbal training has led to positive improvements in verbal production; however, the authors emphasize the importance of trained gestures that follow gesture training protocols. Blake et al. (2013) add that context is key to language recovery in order for the patient to understand ambiguous words, determine a speaker’s intentions, and determine non-literal communication such as metaphors and idioms.

Brady et al. also identified 25 studies (n=910) comparing one type of SLT with another (Brady et al. 2012). Across the 11 different treatment comparisons, few significant between group differences were identified. The authors concluded that although the results of the review generally favour SLT over no treatment/communication stimulation, there is insufficient evidence to support any specific types of therapy (Brady et al. 2012). However, when interpreting these results, it is important to note that the aphasia literature presents several potential sources of bias, including lack of sample size calculations, use of non-standardized outcome assessments, lack of clarity regarding aphasia types and levels of severity, and undocumented details of therapy (Kelly et al., 2010). Moreover, potential benefits of intensive SLT over conventional SLT may be confounded by significantly higher dropout from intensive SLT (Brady et al., 2012).

In a review examining the association between SLT intensity and treatment effect, Bhogal et al. identified 10 controlled trails examining SLT post-stroke and found that studies with more intensive therapy provision were more likely to report significant positive treatment effects whereas studies with less intensive therapy provision were more likely to report non-significant treatment effects (Bhogal et al., 2003). Bhogal and colleagues concluded that intense SLT over a short period of time is associated with improved outcomes of speech and language for patients with post-stroke aphasia. Likewise, in their Cochrane review, Brady et al. concluded that intensive speech and language therapy appears to be have some benefit in terms of functional communication, writing, and severity of impairment (Brady et al., 2012). However, an RCT conducted by Martins et al. (2013) compared intensive and regular speech and language therapy and found that although intensive therapy demonstrates a trend towards greater improvement than regular therapy, no statistically significant differences between the two interventions were found on any of the outcome measures. It should be noted that the authors state that the lack of statistical significance may have been due to the small sample size (Martins et al. 2013). Similarly, an RCT conducted by van der Meulen et al. (2014) compared two groups over two study periods with the experimental group receiving Melodic Intonation Therapy (MIT) during the first period followed by regular treatment during the second period whilst the control group were delayed and received MIT during the second study period only. Van der Meulen et al. (2014) found no significant difference in levels of treatment intensity (p=0.49) but did find that treatment intensity was significantly predictive of outcome on the repetition of trained items in MIT (p=0.02). It was also reported that receiving MIT later after being delayed was associated with less improvement thus indicating that timing of rehabilitation is crucial for language recovery.

Further research has advocated for therapy early post-stroke to reduce the long-term effects of aphasia. Godecke et al. (2013) report that the amount of therapy in early post-stroke recovery was a significant predictor of recovering from aphasia (p=0.030); however, frequency of therapy sessions was not a significant predictor. Thus, it can be concluded that timing of interventions may be as important as frequency of participation. These findings were replicated by Godecke et al. (2014) who compared early rehabilitation with a usual care group and found patients in the early rehabilitation group demonstrated a greater level of recovery with an 18% higher score on the Western Aphasia Battery Quotient than usual care patients. These improvements were maintained up to 6 months post-stroke with early rehabilitation patients exhibiting a 16% advantage over usual care patients (Godecke et al. 2014).

There is some evidence that group SLT and/or volunteer-facilitated SLT may represent effective means of supplementing available speech language resources and/or to increase the intensity of SLT, where appropriate. Brady and colleagues identified three trials comparing group SLT to conventional SLT and four trials comparing volunteer-facilitated SLT to professional SLT: with respect to both comparisons, outcomes obtained in group and volunteer-facilitated SLT were similar to those obtained in conventional therapy delivered by trained professionals (Brady et al. 2012).

A review by Hilton et al. (2014) revealed a number of recommendations for clinicians and relatives in order to further improve care for stroke patients. Recommendations include providing greater amounts of information to patients to reduce anxiety, informing and warning relatives of potential difficulties in the transitions from hospital to home and providing coping strategies that can be utilized by patient and relative, and for clinicians to be aware of the need for psychosocial support. Research from Nykanen et al. (2013) investigated the efficacy of the Communication Therapy for People with Aphasia and their Partners (APPUTE) intervention, a program designed to improve communication between patients and relatives, and found that patients improved significantly from baseline to the end of rehabilitation in communication efficiency (MD = –1.053, SE = .352, p=0.016, 95% CI [–1.940, –.167]) and on the Western Aphasia Battery (MD   = –3.471, SE = .708, p<0.001, 95% CI [–4.911, –2.030]). Partners of patients also demonstrated consistent improvement with significant changes in communication skills found between baseline and the end of the first rehabilitation period (MD = –1.667, SE = .165, p<0.001, 95% CI [–2.128, –1.206]) and between the first and end of the second rehabilitation period (MD = –3.951, SE = .245, p<0.001, 95% CI [–4.635, –3.266]) (Nykanen et al. 2013).