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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

7. Language and Communication

Recommendations and/or Clinical Considerations
  1. Healthcare providers working across the continuum of care should undergo training about aphasia and other communication disorders, including recognition of the impact of aphasia and methods to support communication [Strong recommendation; Low quality of evidence]. 

    Note: Other communication disorders may include dysarthria, apraxia of speech and cognitive communication deficits. 
  2. All individuals with stroke should be screened for communication impairments, ideally by a healthcare professional with expertise in communication, using a validated screening tool [Strong recommendation; Low quality of evidence].
  3. Individuals with stroke with suspected communication impairments should be assessed by a Speech-Language Pathologist (SLP) or other healthcare provider with expertise in communication impairments, using standardized, valid assessment to identify impairments, activity limitations, participation restrictions, and the impact on relationships related to communication deficits, across the rehabilitation care continuum [Strong recommendation; Low quality of evidence].
  4. Individuals with aphasia and other communication disorders (e.g., speech apraxia) should have early access to a combination of intensive speech, language, and communication therapy according to their needs, goals and impairment severity to improve functioning [Strong recommendation; High quality of evidence].
  5. Training in supported conversation techniques for potential communication partners of individuals with aphasia should be offered [Strong recommendation; High quality of evidence]. 
  6. All information intended for the use of individuals with aphasia should be available in aphasia-friendly formats [Strong recommendation; Low quality of evidence].
  7. Families of individuals with aphasia should be engaged in the entire process from screening through intervention, including family education and training in supported communication [Strong recommendation; Low quality of evidence].
Section 7 Clinical Considerations
  1. Treatment to improve functional communication may include interventions such as language therapy focusing on impairments-based approaches, conversational treatment, training on use of assistive devices, computer therapy.
    1. Production and/or comprehension of words, sentences and discourse, (including reading and writing), is recommended to improve functional communication.
    2. Use of non-verbal strategies, assistive devices and technology (e.g., iPads, Tablets, other computer-guided therapies), which can be incorporated to improve communication.
    3. Use of computerized language therapy for reading practice and word finding and to enhance benefits of other therapies.
  2. Treatment for aphasia may include group therapy and conversation groups. Groups can be used to supplement the intensity of therapy during hospitalization and/or as continuing therapy following discharge.
  3. Individuals with aphasia should be assessed for their potential to benefit from using augmentative alternative communication modalities (e.g. iPad, tablet, electronic devices, alphabet board) or other communication support tools, ideally that are culturally relevant.
Rationale +-

Aphasia, which is a common consequence of stroke, is associated with challenges in speaking, reading, writing, and comprehension. Acutely, it is estimated that between 21% and 38% of stroke patients are aphasic. 186, 187 This condition significantly impacts an individual’s ability to express themselves and understand others. Individuals with aphasia may struggle to find the right words, form coherent sentences, or follow conversations, which can lead to frustration, social withdrawal, and decreased quality of life. Other communication impairments following stroke include dysarthria, apraxia of speech and cognitive-communication disorders. Communication barriers not only affect personal interactions but can also hinder participation in rehabilitation, access to essential services, community participation and an increased risk for mortality. Aggressive management of aphasia helps to improve both language and broader recovery.

Individuals with stroke have emphasized the necessity of early screening and assessment for language and communication changes following stroke and the importance of access to rehabilitation to improve communication and language. Aphasia challenges can have a significant impact for the individual with stroke, their family members, and caregivers. Individuals with stroke express that difficulties in these areas can have a profound impact on their self-esteem and relationships. Availability and accessibility of individualized therapy, specialists and virtual rehabilitation regardless of financial limitations and geography, that help with communication and language are recognized as important elements of recovery. 

Performance Measures +-

System Indicators

  1. Proportion of staff members in each rehabilitation setting trained on supportive communication techniques.
  2. Access to speech-language and specialized aphasia services in each region.
  3. Proportion of individuals experiencing aphasia or other communication issues following an acute stroke.

Process Indicators

  1. Proportion of individuals with stroke screened for aphasia during acute inpatient admission; and during initial assessment in a rehabilitation setting.
  2. Proportion of individuals with stroke with aphasia who receive a detailed assessment by a speech-language pathologist prior to leaving acute care.
  3. Median time from hospital discharge to initiation of aphasia therapy in the community.
  4. Proportion of time each patient with stroke and communication issues spends in therapy with communication specialist (speech language pathologist or other trainer professional when SLP not available).

Patient-Oriented Indicators

  1. Changes in quality of life for individuals with stroke and aphasia measured at regular intervals during recovery and participation, and reassessed when changes in health status or other life events occur (e.g., at 60, 90- and 180-days following stroke).
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 7

Aphasia, an acquired communication disorder that impairs the ability to process language, speak and understand others, affects 21% to 38% of stroke survivors. 186,187 Aphasia is associated with increased length of hospital stay, inpatient complications, overall neurological disability, mortality and discharge disposition. 188 A Cochrane review189 included 57 RCTs comparing speech-language therapy (SLT) for aphasia after stroke with no SLT, social support or stimulation, or another form of SLT. In total, 74 randomized comparisons, consisting of over 3,000 participants were included in the review. Among the trials comparing SLT vs. no SLT, the interventions described were conventional SLT, (n=12), constraint-induced aphasia therapy (n=1), melodic intonation therapy (n=1), intensive SLT (n=5), group SLT (n=1), volunteer-facilitated SLT (n=2), computer-mediated SLT (n=6), and functionally based SLT involving a communicative partner (n=1). Acupuncture was a co-intervention in 3 trials. Compared with no SLT, speech language therapy was associated with a significant improvement in functional communication (SMD=0.28, 95% CI 0.06 to 0.49), compared with no SLT, along with significant improvements in reading comprehension (SMD= 0.29; 95% CI 0.03 to 0.55), general expressive language (SMD=1.28; 95% CI: 0.38 to 2.19) and written expressive language (SMD=0.41, 95% CI 0.14 to 0.67) immediately after SLT. However, the positive effects were no longer evident at 6 months. No significant differences in outcomes were found between group vs. individual SLT, computer-mediated vs. professional SLT or constraint-induced aphasia vs. other forms of SLT.

The impact SLT has on communication outcome appears to be mediated by the intensity and duration of the therapy. Brady et al. 190 included the results of 25 RCTs and examined the effects of total dose of SLT (hours), intensity (hours/week), frequency (days/week) and duration (total weeks) on communication outcomes post stroke. Mean gains in overall language ability, assessed using the Western Aphasia Battery–Aphasia Quotient, were greatest when total amount of therapy was provided for >20 to < 50 hours (18.37 points, 95% CI 10.58 to 16.16). For functional communication, assessed using the Aachen Aphasia Test-Spontaneous Speech Communication, mean gains were greatest after >14 to 20 hours of therapy (0.94 points, 95% CI 0.34 to 1.55). In terms of intensity of therapy, mean gains from baseline for overall language ability were similar when SLT was provided for up to 2 hours per week (15.85 points, 95% CI 8.06–23.64), 3 to 4 hours per week (15.80 points, 95% CI 8.85 to 22.74) and for 9 or more hours per week (15.64 points, 95% CI 9.14 to 22.13). The pattern was similar for functional communication with the greatest gains for therapy provided for up to 2 hours/week (0.77 points, 95% CI 0.36–1.19) with equivalent gains for 2 to 3 hours/week (0.76 points, 95% CI 0.34–1.18) and 3-4 hours/week (0.70 points, 95% CI 0.35–1.06). The greatest gains in overall language ability and functional communication were achieved when SLT was provided for 5 days per week (14.95 points, 95% CI 8.67–21.23 and 0.78 points, 95% CI 0.48–1.09, respectively). Finally, the greatest gains in overall language ability were associated with SLT that was provided for 11 to 20 weeks (17.27, 95% CI 9.71-24.82), followed by therapy provided for >20 weeks (16.93, 95% CI 8.57-25.29), while therapy provided for <3 weeks was not associated with significant improvement.

A 2016 systematic review, authored by Simmons-Mackie, 191 updated with an additional 25 studies from their previous review in 2010 192 included the results of 56 studies evaluated the effect of education and communication interventions focusing on partner training of individuals with aphasia (mainly stroke and mainly chronic aphasia) and their communication partners.  A variety of types of partner training were studied and included studies involving both partners and individuals with aphasia, and partners alone. In most studies, there was an increase in communication activities and participation between the participant and communication partner. The authors concluded that communication partner training should be conducted to improve partner skills in facilitating the communication of people with chronic aphasia, and additional research is needed to strengthen and expand recommendations related to acute aphasia.

Sex & Gender Considerations

Evidence from two recent systematic reviews and meta-analyses suggest that the risk of aphasia following stroke is higher in women. Li et al. 193 included the results from 36 papers (n= 31,058) and reported the odds of post-stroke aphasia were higher in women (36% vs. 31%, OR= 1.23, 95% CI 1.19 to 1.29). A similar result was found by Wallentin 194 who included the results from 25 studies (29.6% vs. 26.0%, RR= 1.139, 95% CI 1.100 to 1.180).

In a companion study examining the association between SLT outcomes and therapy provision, Brady et al. 195 reported sex-related differences in response to SLT. For women, the greatest gains in functional communication were associated with lower levels of SLT (provided for 4 days/week, <2 hours/week for a total of 14-20 hours), compared with men where higher intensity therapy was associated with higher gains (SLT provided for >5 days/week, 3-4 hours/week for a total of ≥50 hours).

Stroke Resources
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