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Stroke Rehabilitation

10. Rehabilitation to Improve Language and Communication

February 2016 - 2016 UPDATE

Rehabilitation to Improve Language and Communication

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Rehabilitation to Improve Language and Communication, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS.

For the French version of these recommendations, open the appendix at this link.

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through this website, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale +-

Aphasia is defined as the loss of ability to communicate orally, through signs, or in writing, or the inability to understand such communications. Aphasia is one of the most common consequences of stroke in both the acute and chronic phases. Acutely, it is estimated that between 21 – 38% of stroke patients are aphasic. The presence of aphasia has been associated with general decreased response to stroke rehabilitation interventions and an increased risk for mortality. Aggressive management of aphasia helps to improve both language and broader recovery.

System Implications +-

Patients with communication deficits, and their family members and caregivers, require access to specialized inpatient and community-based communication services following their stroke:

  • Programs and services should be in place in all organizations and communities with easy access and appropriate support for stroke patients with communication impairments, including access to speech-language pathologists
  • Telemedicine technology should be strongly considered and actively utilized, particularly in areas with limited in-person access to speech-language pathologists, to ensure equity in rehabilitation opportunities for people with post-stroke aphasia
  • Community support programs and peer-support groups should be established and information should be readily available in acute care and the rehabilitation settings for patients to access these groups
Performance Measures +-
  1. Percentage of patients screened for aphasia during acute inpatient admission; and during initial assessment in a rehabilitation setting.
  2. Percentage of patients 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. Number of staff members in each rehabilitation setting trained on supportive communication techniques.
  5. Percentage of time each patient with strike and communication issues spends in therapy with communication specialist (speech language pathologist or other trainer professional when SLP not available).
Summary of the Evidence +-

Evidence Table 10

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).

Stroke Resources