Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 May 22:23969873241311025.
doi: 10.1177/23969873241311025. Online ahead of print.

European Stroke Organisation (ESO) guideline on aphasia rehabilitation

Marian C Brady  1 , Claire Mills  2   3 , Hege Prag Øra  4   5 , Natalia Novaes  6 , Frank Becker  4   5 , Fofi Constantinidou  7 , Agnes Flöel  8 , Katharina S Sunnerhagen  9 , Jytte Isaksen  10   11 , Caroline Jagoe  12 , Luis Mt Jesus  13 , Paola Marangolo  14 , Marcus Meinzer  8 , Ineke van der Meulen  15   16 , Pauline Campbell  1 , Leonard Ho  17   18 , Salman Hussain  18 , Katerina Hilari  19
Affiliations

European Stroke Organisation (ESO) guideline on aphasia rehabilitation

Marian C Brady et al. Eur Stroke J. .

Abstract

Evidence of effective aphasia rehabilitation is emerging, yet intervention and delivery varies widely. This European Stroke Organisation guideline adhered to the guideline development standard procedures and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The resulting multi-disciplinary, evidence-based recommendations support the delivery of high-quality stroke-related aphasia rehabilitation. The working group identified 10 clinically relevant aphasia rehabilitation questions and rated outcomes' relevance and importance. Following systematic searching, independent reviewers screened title-abstracts and full-texts for randomised controlled trials of speech-language therapy (SLT) for stroke-related aphasia. Results were profiled using PRISMA. Risk-of-bias was evaluated using the Cochrane Risk-of-Bias 1 tool. We prioritised final-value data. Where possible we conducted meta-analyses (RevMan) using random effects and mean, standardised mean differences (functional communication, quality of life, aphasia severity, auditory comprehension and spoken language outcomes) or odds ratios (adverse events). Using GRADE, we judged quality of the evidence (high-to-very low) and ESO recommendation strength (very strong-to-very weak). Where evidence was insufficient to support recommendations, expert opinions were described. Based on low-quality evidence we recommend the provision of higher total SLT dose (⩾20 h) and suggest higher SLT intensity and frequency to improve outcomes in aphasia rehabilitation. Similarly, we suggest the provision of individually-tailored SLT and digital and group therapy delivery models. Very low-level evidence for transcranial direct current stimulation (tDCS) with SLT informed the expert consensus that such interventions should only be provided in the context of high-quality trials. Evidence-based clinical-research priorities to inform SLT aphasia rehabilitation intervention choice and delivery are highlighted.

Keywords: Guideline; aphasia; brain stimulation; meta-analysis; speech and language therapy; stroke; systematic review.

Plain language summary

A third of stroke survivors develop aphasia resulting in problems speaking, understanding speech, reading and writing. Aphasia is associated with depression and poorer stroke recovery. This guideline addresses important questions to support optimal speech and language therapy for aphasia rehabilitation. We considered the available evidence and analysed data from 45 trials. We make the following recommendations and multidisciplinary expert consensus statements to support aphasia rehabilitation clinical decisions.In people with aphasia post-stroke to improve language, communication and quality of life we recommend speech and language therapy interventions of ≥ 20 hours (rehabilitation dose).we suggest speech and language therapy ≥ 4 days per week (rehabilitation frequency).we suggest ≥ 3 speech and language therapy hours per week (rehabilitation intensity).we suggest that speech and language therapy can be delivered in-person or digitally (digital rehabilitation).we suggest using either one-to-one or group speech and language therapy. The decision on the format of the therapy intervention may be made with reference to the health service context and resources available (rehabilitation context).we suggest that speech and language therapy should be tailored to the person with aphasia so that it is functionally relevant and at the right level of language difficulty for their rehabilitation needs (tailoring rehabilitation).we suggest that augmentation of in-person speech and language with digital therapy should be offered (in-person or digital therapy).Where research information was lacking, and clinical uncertainties remained we developed the following expert consensus statements to guide clinical decision making where access to one-to-one therapy is constrained by resource availability, we suggest that group therapy delivered in addition to one-to-one speech and therapy may facilitate increased therapy time, provide additional opportunities to use language in a social context, and enhance communication confidence. We also suggest that the therapy timing and format should follow other recommendations in this clinical guideline, aiming to enhance language recovery, communication, participation, and quality of life (augmenting dose).we suggest that in the clinical context, speech and language therapy should be delivered alone rather than with transcranial direct current stimulation. Further evidence is required of the effectiveness of SLT with such brain stimulation. Individualised approaches to the brain stimulation rehabilitation delivery protocol for people with aphasia may be beneficial, but again, further evidence is required (brain stimulation and speech and language therapy).

PubMed Disclaimer

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Risk of bias profile for studies included in PICO 1 (immediately postintervention) analysis.
Figure 2.
Figure 2.
(a) PICO 1 Functional communication and (b) PICO 1 Quality of Life.
Figure 3.
Figure 3.
Risk of bias profile for studies included in PICO 2 (immediately postintervention) analysis.
Figure 4.
Figure 4.
(a) PICO 2 Functional communication and (b) PICO 2 Quality of Life.
Figure 5.
Figure 5.
Risk of bias profile for studies included in PICO 3 (immediately postintervention) analysis.
Figure 6.
Figure 6.
(a) PICO 3 Functional communication and (b) PICO 3 Quality of Life.
Figure 7.
Figure 7.
Risk of bias profile for studies included in PICO 4a (immediately postintervention) analysis.
Figure 8.
Figure 8.
(a) PICO 4a Functional communication and (b) PICO 4a Quality of Life.
Figure 9.
Figure 9.
Risk of bias profile for studies included in PICO 4b (immediately postintervention) analysis.
Figure 10.
Figure 10.
PICO 4b Functional communication.
Figure 11.
Figure 11.
Risk of bias profile for studies included in PICO 5a (immediately postintervention) analysis.
Figure 12.
Figure 12.
(a) PICO 5a Functional communication and (b) PICO 5a Quality of Life.
Figure 13.
Figure 13.
PICO 5b Risk of bias profile for studies (immediately post intervention) analysis.
Figure 14.
Figure 14.
(a) PICO 5b Functional communication and (b) PICO 5b Quality of Life.
Figure 15.
Figure 15.
PICO 6a Risk of bias profile for studies included (immediately post intervention) analysis.
Figure 16.
Figure 16.
(a) PICO 6a Functional communication, (b) PICO 6a Quality of Life, (c) PICO 6b Functional communication, and (d) PICO 6d Functional communication.
Figure 17.
Figure 17.
Risk of bias profile for studies included in PICO 7b (immediately post intervention analysis).
Figure 18.
Figure 18.
PICO 7b Quality of Life.
See this image and copyright information in PMC

References

    1. Worrall L, Simmons-Mackie N, Wallace SJ, et al.. Let’s call it “aphasia”: rationales for eliminating the term “dysphasia”. Int J Stroke 2016; 11: 848–851. - PubMed
    1. Dickey L, Kagan A, Lindsay MP, et al.. Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada. Arch Phys Med Rehabil 2010; 91: 196–202. - PubMed
    1. Feigin VL, Brainin M, Norrving B, et al.. World Stroke Organization (WSO): global stroke fact sheet 2022. Int J Stroke 2022; 17: 18–29. - PubMed
    1. Gialanella B, Bertolinelli M, Lissi M, et al.. Predicting outcome after stroke: the role of aphasia. Disabil Rehabil 2011; 33: 122–129. - PubMed
    1. Hilari K, Northcott S. “Struggling to stay connected”: comparing the social relationships of healthy older people and people with stroke and aphasia. Aphasiology 2017; 31: 674–687.

LinkOut - more resources