What therapy is recommended for dysphagia (difficulty swallowing) after a stroke?

Management of Dysphagia After Stroke

For post-stroke dysphagia, a comprehensive approach including early screening, individualized therapy with both restorative techniques and compensatory strategies, and appropriate nutritional support is strongly recommended to reduce complications and improve outcomes.

Initial Assessment and Screening

• All stroke patients should be screened for swallowing deficits as soon as they are alert and ready for oral intake, using validated screening tools, ideally by a speech-language pathologist (SLP) or another appropriately trained professional 1
• Screening should occur before the patient begins eating, drinking, or receiving oral medications to prevent aspiration 1
• Patients who fail initial screening should be kept NPO (nothing by mouth) until comprehensive assessment 2
• Abnormal screening results should prompt referral to a speech-language pathologist, occupational therapist, and/or dietitian for more detailed assessment 1
• Instrumental evaluation using videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed for patients at risk for pharyngeal dysphagia or poor airway protection 1, 3

Therapeutic Approaches

Restorative Therapy

• Implement restorative swallowing therapy including:
  • Lingual resistance exercises 1
  • Breath holds and effortful swallows 1
  • Shaker exercises and chin tuck against resistance 2
  • Regular therapy sessions (at least 3 times weekly) for as long as functional gains are observed 2, 4

Compensatory Techniques

• Implement compensatory strategies including:
  • Postural adjustments (chin tuck, head rotation) 1, 2
  • Sensory enhancement with bolus modifications 1
  • Volitional control techniques 1
  • Texture modification of foods and liquids 1, 2
  • Proper positioning during meals (seated upright) 2, 4
  • Slow feeding rate with small amounts per bite 2

Nutritional Management

• Develop an individualized management plan addressing therapy for dysphagia, dietary needs, and specialized nutrition plans 1
• For patients unable to maintain adequate nutrition orally, consider enteral feeding within 7 days of admission 1, 2
• Use nasogastric tube feeding for short-term (2-3 weeks) nutritional support 1
• For longer-term feeding needs, consider percutaneous endoscopic gastrostomy (PEG) tubes, which are associated with fewer treatment failures and improved nutritional outcomes 1
• Provide nutritional supplements for patients who are malnourished or at risk of malnourishment 1, 2

Oral Hygiene and Pneumonia Prevention

• Implement meticulous mouth and dental care to reduce the risk of aspiration pneumonia 1
• Educate patients on the importance of good oral hygiene 1
• Encourage patients to feed themselves whenever possible to reduce pneumonia risk 1
• Implement oral hygiene protocols consistent with dental association recommendations 1

Monitoring and Follow-up

• Regularly reassess swallowing function to adjust therapy and dietary modifications 2
• Monitor for complications such as aspiration pneumonia, malnutrition, and dehydration 2, 5
• Continue swallowing therapy as long as the patient demonstrates functional improvements 2, 4

Interdisciplinary Approach

• Management should involve a specialized rehabilitation team including speech-language pathologists, dietitians, physicians, and nurses 2
• Provide education to patients, families, and caregivers on swallowing and feeding recommendations 1, 2

Clinical Pearls and Pitfalls

• Early intervention with behavioral swallowing therapy shows better outcomes than usual care, with high-intensity therapy demonstrating superior results for returning patients to normal diet 4
• The presence of facial palsy and larger white matter hyperintensity volume are associated with initial dysphagia and poorer recovery 5
• Standardized physician screening tools like the Modified Mann Assessment of Swallowing Ability can facilitate earlier identification of dysphagia when SLPs are not immediately available 6
• Instrumental assessment is crucial as bedside evaluations alone cannot reliably predict aspiration, as patients can aspirate without obvious clinical signs 1, 3
• The chin-tuck posture provides aspiration protection in fewer than 50% of neurogenic dysphagia cases, so individualized positioning recommendations based on instrumental assessment are essential 2