Clinical Decision Making in Patients with

Stroke-Related Dysphagia
Cecilia C. Felix, M.A., CCC-SLP,1
Megan E. Joseph, M.Ed., CCC-SLP,1,2 and
Stephanie K. Daniels, Ph.D., CCC-SLP2

ABSTRACT

This article aims to highlight stroke considerations in the

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evaluation and management of dysphagia. Although dysphagia was
previously thought to occur only following brainstem or bilateral cortical
strokes, the development of brain imaging and dynamic swallowing
studies has revealed small, unilateral supratentorial strokes can produce
dysphagia. In this article, screening, evaluation, and management of
dysphagia are outlined, as well as the clinical decision making that
occurs when taking into account cognitive and communication deficits
that may be present. For the clinical swallow examination, chart review,
interview, informal evaluation of cognition and communication, obser-
vation of posture, oral cavity inspection, cranial nerve examination, and
the direct swallowing assessment are reviewed along with tailoring of
each according to the deficits observed. Specific compensation and
rehabilitation strategies are discussed along with how cognitive and
communication deficits can guide the clinician’s decision-making
process to select an appropriate plan of care. A case study is provided
to synthesize the process into a real-world scenario.

KEYWORDS: dysphagia, stroke, rehabilitation, assessment/

evaluation

Learning Outcomes: As a result of this activity, the reader will be able to (1) discuss the various levels of
swallowing evaluation and identify the information obtained with each; (2) implement knowledge of the clinical
swallowing examination to increase the extent of information obtained in the evaluation; and (3) summarize
the factors to consider when implementing management strategies in patients with stroke-related dysphagia.

1
Department of Speech Pathology, Memorial Hermann
Health System, Houston, Texas; 2Department of Commu-
nication Sciences and Disorders, University of Houston,
Houston, Texas.
Address for correspondence: Stephanie K. Daniels,
Ph.D., CCC-SLP, Department of Communication
Sciences and Disorders, University of Houston, 4455
Cullen Blvd., Houston, TX 77204-6018
(e-mail: skdaniels@uh.edu).
188
Clinical Decision Making in Dysphagia; Guest Editors,
Gary H. McCullough, Ph.D., CCC-SLP and Balaji Ran-
garathnam, Ph.D., CCC-SLP.
Semin Speech Lang 2019;40:188–202. Copyright
# 2019 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
4662.
DOI: https://doi.org/10.1055/s-0039-1688815.
ISSN 0734-0478.
 CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
A wide discrepancy in the incidence of
dysphagia in adults following stroke, ranging
from 25 to 81%, has been reported.1 This
variability is, in part, the result of discrepancies
in evaluation procedures, as well as various
definitions and classifications for determining
dysphagia. When utilizing a comprehensive
swallowing evaluation, such as the videofluo-
roscopic swallowing study (VFSS), the inci-
dence of dysphagia following acute stroke is
approximately 50%,2 with the incidence of
aspiration occurring in about one-half of those
individuals with dysphagia.3
Prior to the advent of in vivo brain imaging
studies and dynamic swallowing studies such as
VFSS, it was generally posited that dysphagia
could only occur following a brainstem or
bilateral cortical stroke. Imaging studies, howe-
ver, have allowed us to correlate structure and
function leading to knowledge that a single
cortical or subcortical stroke in either the right
or left hemisphere can produce dysphagia.4,5
While diffusion-weighted acquisition comple-
ted during magnetic resonance imaging (MRI)
brain scans allows immediate identification of
small, acute infarcts, other acquisition methods
of MRI, as well as computed tomography scans,
can also provide insight into structure–function
relationships in swallowing. It is a common
assumption that stroke volume must be large
with a corroborating high National Institute of
Health Stroke Scale Score to produce dyspha-
gia. Research, however, has demonstrated that
mild stroke and small lesion volume can pro-
duce dysphagia.4,6–9
SWALLOWING SCREENING
There are three levels in the evaluation of
swallowing: screening, clinical swallowing exa-
mination (CSE), and instrumental assessment.
The purpose of swallowing screening is to
determine who is at risk of dysphagia and/or
aspiration. As screenings are designed to be
completed on everyone in a population in which
there is a high risk of the problem, in the case of
stroke, the swallowing screening should be
completed on all individuals admitted to hos-
pital with suspected stroke including those
patients with mild stroke. Per recommenda-
tions of the American Heart Association/
189
American Stroke Association (AHA/ASA),
all individuals presenting with suspected stroke,
regardless of severity or symptoms, should be
maintained nil per os (NPO), or nothing by
mouth including oral medications, until scree-
ning is completed.10 If the screening proves
negative, that is, the person passes, oral intake
can begin. If the screening is positive, that is,
the individual fails, nonoral intake is main-
tained and speech–language pathology consult
is expedited. The screening does not provide
information that contributes to the hypothesis
of underlying swallowing impairment and
development of a management plan.
A swallowing screening is designed to be
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quick and rapidly administered, typically by nur-
ses, either in the emergency department or once
the patient is admitted to the hospital. Training of
nurses or any group of health care providers is
essential for accurate implementation and inter-
pretation of the swallowing screening tool (SST),
as they do not have the training or day-to-day
experience in identifying signs associated with
dysphagia. It is important to also remember that
nurses have many responsibilities other than
swallowing screening, so the time commitment
to education and maintenance of skills must also
be feasible. Review of available SSTs suggests
variable times necessary for education including
10 minutes for the Barnes Jewish-Hospital-Stroke
Dysphagia Screen (BJH-SDS),11 1 hour for the
Rapid Aspiration Screening for Suspected Stroke
(RAS3),12 and 4 hours for the Toronto Bedside
Swallowing Screening Test (Tor-BSST).13
Regardless of the initial training time, one must
consider the best way to deliver the education so
that it is feasible for speech–language pathologists
(SLPs) given nurses’ rotating schedules and the
frequent addition of new nurses. In this regard,
some form of web-based training may be best;
however, this should be followed by hands-on
practice with a standardized patient actor or with
actual patients.14 Moreover, booster sessions in
the form of web-based models may be required to
facilitate initial education to sustain high adhe-
rence and reliability.
There are currently five available SSTs that
have been validated for patients for stroke, tested
against instrumental assessment, and designed
for nurses or other frontline health care providers
to administer. These screening tools are the
190 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
BJH-SDS,11,15 Gugging Swallowing Screen,16
RAS3,12,17 TOR-BSST,13 and the 3-oz Water
Swallow Challenge/Yale Swallow Protocol.18–20
While there is currently no consensus on a single
best SST for patients with suspected stroke, this
does not mean that screening should not be
completed. Rather it suggests that the stakehol-
ders in the stroke SST should carefully review
the strengths and limitations of the research for
each available screening and then select the one
that most meets their needs.
Various models in which an SST can be
implemented are available.21 Many hospitals
may follow a model in which the stroke SST is
completed by a frontline health care provider
such as a nurse, and only patients who fail the
screening receive a speech–language pathology
consult for a CSE. This model, however, may
not be the best process for stroke. Patients
frequently present with cognitive deficits such
as decreased attention, neglect, or impulsive-
ness, which may affect swallowing,22–24 and
may be missed by a routine SST. It is, thus,
suggested that SLPs be consulted to complete a
CSE on all individuals admitted with stroke.
For patients who pass the swallowing screening,
oral intake can be initiated, and the consult to
the SLP need not be expedited. Moreover, in
this day of rapid discharge, it would allow the
SLP the opportunity to screen for cognitive and
language deficits that may be missed during the
neurological workup.
CLINICAL SWALLOW
EXAMINATION
The CSE is designed to determine the need for
instrumental assessment, guide decision
making regarding oral diet initiation/continua-
tion and identify critical information to help
guide any potential management plan. This is
accomplished by completing a chart review and
patient interview, cognitive and communica-
tion informal assessment, observation of gross
motor skills and oral cavity inspection, cranial
nerve assessment, and evaluation of swallowing.
Chart Review and Patient Interview
Gathering information regarding the patient’s
prior and current level of function is imperative
2019
to any CSE. A thorough chart review should
include neurological damage, structural chan-
ges, diagnostic imaging, relevant consultations,
current medications, appropriate laboratory
results, and history of dysphagia with any
previous evaluations and/or treatment.
The interview portion can fill in any mis-
sing information not available during the chart
review; although the amount of information
gathered can vary widely based on the setting in
which it is completed and the patient’s ability.
At the inpatient level, the SLP may be consul-
ted for a failed swallowing screen, reduced oral
intake, or signs of dysphagia during oral intake.
The patient may not realize that there is a
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concern for swallowing as he/she has had no
opportunity to eat or drink since admission or
the patient may be unaware of deficits. Com-
pleteness and accuracy of the interview may be
affected by level of alertness, cognitive, and
language deficits. Conversely, some patients
with acute stroke may be very aware of their
swallowing problems and contribute important
information during the interview. At the out-
patient level, the patient may be coming in for a
specific complaint related to his/her swallowing
and provide great detail. In either location, it is
important to start with an open-ended request,
“Tell me about your swallowing,” and then
determine the need for further questions based
on the response. If family is available in either
setting, questions can also be directed to them if
warranted to provide more detailed informa-
tion; however, lack of family availability should
not delay completion of the CSE. The SLP
should attempt to gather details concerning any
history of dysphagia and interventions, baseline
diet, type of difficulty (coughing, food feels
stuck, painful swallow, etc.), onset and duration
of dysphagia, progression of the swallowing
problem (worsening, improving, static), textu-
res with which difficulty occurs, anything that
facilitates swallowing, and level of indepen-
dence for oral intake and hygiene.
Cognition and Communication
Informal Assessment
As many patients with stroke have deficits
in cognition and communication that can
affect swallowing, it is important that SLPs
 CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
informally evaluate cognition and communica-
tion throughout the CSE. The SLP should
determine if the patient can comprehend and
respond to open-ended questions about swal-
lowing, if yes/no questions are required, or if
history needs to be obtained from family due to
decreased comprehension or expression. Like-
wise, during the cranial nerve examination, the
SLP should determine if the patient follows
commands without demonstration or if a model
of the movement is required to facilitate com-
prehension. As the patient is talking, in addi-
tion to focusing on content and language
abilities, the clinician should assess the patient’s
vocal quality paying particular attention to
breathy or wet vocal quality as these may
indicate reduced true vocal fold (TVF) adduc-
tion or pooling of material on the TVFs,
respectively. Lastly, motor speech disorders
such as dysarthria and apraxia of speech should
be identified. As with communication, the SLP
will want to informally assess cognition in terms
of alertness, memory, attention, neglect, and
impulsiveness throughout the CSE.
Observation of Physical Presentation
and Oral Cavity Inspections
Throughout the CSE, the SLP should observe
the overall presentation of the patient making
note of the patient’s posture (e.g., sitting
upright or leaning to one side), decreased or
unilateral movements of the extremities, which
could be related to hemiparesis or neglect,
contractures, and overall appearance. This
information helps determine the level of inde-
pendence for self-feeding and oral hygiene as
dependence in these areas is associated with the
development of pneumonia.25
Inspection of the oral cavity should be
completed to assess the integrity of all oral
structures (lips, gums, tissues, dentition, hard
palate, velum, and tongue) as well as the quality
of the structures and overall hygiene. The SLP
should observe salivary production and contain-
ment, color differences, injury, presence and fit
of dental prosthesis, food/debris in the oral
cavity, and odor. Poor oral hygiene has high
specificity in detecting aspiration in the post-
stroke population; however, it has poor sensi-
tivity, so absence of poor oral hygiene does not
191
rule out possibility of aspiration.26 Further-
more, the number of decayed teeth is associated
with development of pneumonia.25
Cranial Nerve Examination
The cranial nerve examination can highlight
decreased sensation, range of motion (ROM),
symmetry, and strength of orofacial muscula-
ture that may result in deficits during the oral
phase of swallowing as well as provide the SLP
with a unique opportunity to infer potential
changes to the otherwise unobservable muscu-
lature of the pharynx. Typically subjective
binary judgement (weak, strong) is used during
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cranial nerve examination; however, objective
measures such as the Iowa Oral Pressure Instru-
ment (IOPI) for tongue strength and an analog
peak flow meter to measure volitional cough
flow rate are available with normative data for
tongue strength27 and volitional cough
strength.28 Rather than performing cranial
nerve assessment without thought or inference,
the SLP is encouraged to always consider the
nerve which innervates the muscle and what
other muscles, especially pharyngeal, the nerve
innervates. This adds greater strength to the
examination. See Table 1 for information con-
cerning cranial nerves assessment.
Swallowing Assessment
Presentation of swallowing trials during a CSE
allows the SLP the opportunity to observe signs
of oral and pharyngeal dysphagia in direct
relation to oral intake. The primary reasons to
not directly assess swallowing would be decrea-
sed alertness of the patient or poor secretion
management. Multiple trials of each consis-
tency and volume are ideal to obtain a consistent
measure of a patient’s swallowing. The follo-
wing textures are typically assessed: thin liquids,
semisolids, and solids. As semisolids and solids
can result in pharyngeal residue, which can alter
bolus flow on subsequent trials, it is ideal to
begin the assessment with small volumes of thin
liquid. The amount of aspiration, should it
occur, will be limited if starting with a small
thin liquid volume (e.g., 5 mL). The typical
protocol should test gradual increases of thin
liquids for SLP-regulated volumes (5 and
192 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

Table 1 Cranial Nerve Assessment

Cranial nerve Muscles Assessment examples Potential effects

V: Trigeminal - Temporalis - Open and close jaw - Reduced mastication

- Masseter against resistance - Reduced sensation of
- Medial and lateral pte- - Jaw lateralization oral residue
rygoids - Sensation to the lower - Decreased superior
- Anterior digastric face, palate, and oral hyolaryngeal
- Mylohyoid tongue movement
- Tensor veli palatini - Palpate larynx during
swallowing
VII: Facial - Facial muscles (e.g., - Retract, protrude, late- - Poor labial seal
buccinators, orbicula- ralize lips - Lateral sulcus residue
ris oris) - Labial closure against - Decreased superior
- Posterior digastric resistance hyoid movement

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IX: Glossopharyngeal
X: Vagus
IX and X: Pharyngeal plexus
XII: Hypoglossal
- Stylohyoid - Close eyes; raise eye- - Decreased salivation
- Submandibular and brows
sublingual glands - Palpate larynx during
swallowing
- Stylopharyngeus - Sensation bilateral fau- - Delayed pharyngeal
- Parotid glands cial arches, palatine swallow
tonsils, or PPW - Reduced sensation of
BOT residue
- Reduced pharyngeal
shortening with dif-
fuse residue
- Decreased salivation
- Intrinsic laryngeal - Phonation - Breathy voice
muscles - Volitional cough - Reduced glottis clo-
- Sensation of larynx sure with aspiration
and inferior pharynx during the swallow
- Weak cough
- Increased risk for
silent aspiration
- Palatoglossus - Palatal symmetry - Hyper-/hyponasality
- Palatopharyngeus - Nasal resonance - Nasal regurgitation
- Pharyngeal constrictors - Reduced pharyngeal
- Cricopharyngeus shortening with dif-
- Salpingopharyngeus fuse residue
- Levator veli palatini - Reduced UES opening
with pyriform sinus
residue
- Intrinsic and extrinsic - Retract, protrude, ele- - Reduced mastication
lingual muscles vate, depress, latera- - Reduced bolus control
lize tongue - Reduced oral transfer
- Protrude tongue - Oral residue
against resistance - Decreased BOT
retraction with
valleculae residue
 CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
Table 1 (Continued)
Cranial nerve Muscles
Cervical nerve 1 - Geniohyoid
- Thyrohyoid
Abbreviations: BOT, base of tongue; PPW, posterior pharyngeal wall; UES, upper esophageal sphincter.
10 mL) along with patient-regulated volumes
(e.g., putting 30 mL in a cup and having a
patient take a “normal” size swallow). Depen-
ding on a patient’s response to small volumes,
testing sequential swallowing of a larger volume
(e.g., 90 mL) should be completed as most
individuals drink via self-regulated sequential
swallows. For semisolids, the volume should
initially be one teaspoon (5 mL); this can be
increased to a heaping teaspoon on a subsequent
trial. The oral cavity should be inspected for
residue following ingestion of semisolids and
solids. The larynx should be palpated during all
swallows.29,30 While laryngeal palpation will
assist in determining onset of the pharyngeal
swallow and the number of swallows, which
may be indicative of oropharyngeal residue, the
SLP is unable to determine bolus location in
relationship with the onset of hyolaryngeal
movement nor is he/she able to determine the
extent of laryngeal elevation.
Signs of oral dysphagia, which can be
observed, include anterior loss, bolus holding,
multiple lingual gestures, oral residue, and
decreased mastication. Signs of pharyngeal
dysphagia can include throat clearing, coug-
hing, wet vocal quality, and multiple swallows.
While overt signs of throat clearing, coughing,
and wet vocal quality can be an indication of
airway invasion, the absence of these signs
cannot always be associated with no airway
invasion as many patients with stroke silently
aspirate. It is, therefore, important to not
depend solely on the patient’s response during
oral intake to determine the presence or absence
of dysphagia, but rather, the SLP synthesizes all
information gathered during the comprehen-
sive CSE to generate appropriate recommenda-
tions concerning the need for further
193
Assessment examples Potential effects
- Palpate larynx during - Decreased UES open-
swallowing ing due to decreased
anterior laryngeal
movement with pyri-
form sinus residue
- Decreased laryngeal
elevation
assessment and initiating, continuing, or hal-
ting oral intake. Rather than integrating the
components of a comprehensive CSE, the SLP
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may opt to use the Mann Assessment of Swallo-
wing Ability31 as a standardized CSE for stroke.
INSTRUMENTAL EVALUATION
The goals of the instrumental evaluation in the
diagnosis of stroke-related dysphagia are (1)
evaluation of biomechanical and physiologic
function and dysfunction, (2) determination
of swallowing safety and efficiency, (3) identi-
fication of effective compensatory management,
(4) determination of appropriate diet, and (5)
determination of rehabilitation approaches.
While there are various types of instrumental
evaluations available with each having strengths
and limitations, the VFSS is the preferred
initial evaluation for individuals with stroke-
related dysphagia, as it allows for direct assess-
ment of oral, pharyngeal, and esophageal stages
with the ability to identify underlying swallo-
wing impairments during the oral and pharyn-
geal phases of swallowing. This information is
required to determine the rehabilitation plan.
Various commercially available VFSS measure-
ment tools such as the MBSImP32 and Swal-
lowtail (Belldev Medical, Arlington Heights,
IL) with corresponding normative data33 are
available. The videoendoscopic evaluation of
swallowing (VEES) may be preferred, however,
for individuals who are medically fragile, ven-
tilator dependent, or have contractures in which
positioning would be problematic, as the testing
equipment is portable, and the evaluation can be
completed bedside. Moreover, VEES is an
excellent follow-up assessment to document
improvement in swallowing signs during
194 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
rehabilitation, for example, no aspiration, redu-
ced valleculae residue, without exposing the
patient to further radiation. Manometry, both
low resolution and high resolution, may be a
good adjunctive evaluation if abnormalities in
pharyngeal or upper esophageal sphincter
pressure and/or mistiming of muscular contrac-
tion are suspected.34
The protocol for the swallowing tasks in
VFSS should be similar to the protocol used in
the CSE in which various volumes, consisten-
cies, and trials are tested. Unlike the CSE, the
duration of the VFSS is restricted due to
radiation exposure. Like the CSE, the SLP
starts with small thin liquid volumes (5 mL) of a
contrast agent and gradually increases the volu-
mes depending on a patient’s performance. This
is of particular importance when evaluating
individuals with frontal lobe or right hemi-
sphere damage (RHD), as they can exhibit
reduced inhibition, judgment, and impulse
control. Ideally, two to three trials of each
volume and/or consistency are evaluated35;
swallowing on command is omitted as it can
affect bolus positioning and timing,36 and
patients should self-administer all volumes
and consistencies. As individuals with stroke
may have paralysis, some assistance in feeding
may be required. Likewise, if a person demonst-
rates poor attention and/or poor awareness
which are not uncommon following RHD,
the SLP may need to verbally “command” the
patient to swallow.
If a patient demonstrates consistent airway
invasion or post-swallow residual, then the SLP
must test effects of compensatory strategies.
Knowledge about cognition and comprehen-
sion obtained from the CSE is critical to
determine which strategies should be evaluated.
The SLP may opt to not evaluate strategies such
as 3-second bolus hold or chin tuck, as these
require memory and attention as well as strict
supervision if cognition is compromised and
may instead trial nectar thick liquids which do
not rely on a patient’s cognition. If this consis-
tency proves to prevent aspiration, the SLP can
continue the liquid protocol with nectar thick
liquids. However, depending on the length of
the VFSS and the internal evidence from the
client, the SLP may also choose to evaluate
strategies such as chin tuck and/or 3-second
2019
bolus hold to determine if larger volumes of thin
liquid can be safely swallowed for pleasure with
supervision or to implement as a compensatory
strategy during mealtime as the patient’s
memory improves. Conversely, the SLP can
follow up with VEES to test these other
compensatory strategies as cognition improves.
Some compensatory strategies such as the
Mendelsohn maneuver can be difficult to learn
even in individuals with intact comprehension
and cognition. If findings from the CSE sug-
gest that the Mendelsohn maneuver may be
indicated, ideally the SLP can attempt to teach
it prior to the VFSS. If this cannot be achieved,
the SLP can address teaching the maneuver in
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therapy and then follow up with a repeat VFSS
to determine if the maneuver is performed
correctly and achieving desired results. As
some compensatory strategies may have nega-
tive effects, for example, effortful swallow
which can result in nasal redirection37 and
decreased pharyngeal shortening and increased
hypopharyngeal residue,38 the SLP must test all
strategies in VFSS prior to recommendation.
MANAGEMENT
In determining the appropriate treatments for
individuals with dysphagia following stroke, a
clinician must consider several factors in
management, specifically in regard to compen-
sation and rehabilitation. Frequently, both are
recommended for patients and are addressed
simultaneously. That is, if required for a safe
and efficient swallow, a compensatory strategy
is recommended during intake and rehabilita-
tive strategies are targeted during swallowing
therapy to address the underlying impairment.
In determining the best recommendations for
compensation and rehabilitation, the SLP must
consider both external and internal evidence.
External evidence is the quality of the research
to support the treatment, and internal evidence
pertains to patient, family, and environmental
factors, including patient goals.
For individuals with stroke, considerations
need to be made for deficits in cognition or
comprehension that may serve as a barrier for
participation in therapy. For these patients,
rehabilitation may need to be postponed until
improvement occurs and direct supervision will
 CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
likely be required for implementation of com-
pensatory techniques. For individuals who are
weak or deconditioned, rehabilitation can still
be targeted, although at a reduced intensity.
Compensation
Compensatory strategies are designed to allow a
person to achieve a safe and efficient oral diet by
eliminating signs of dysphagia, for example,
aspiration, residue. Even though some research
has suggested correlation between the CSE and
VFSS in broad diet recommendations,39 nume-
rous studies support the need for instrumental
evaluation to determine the need for and effec-
tiveness of any recommended compensa-
tion40–42 and ensure no negative effects as
discussed previously. However, if only oral stage
dysphagia is suspected in the CSE, compensa-
tions such as solid bolus alteration to minced
and moist or cyclic ingestion to clear oral
residue can be evaluated without instrumental
assessment.
Some compensatory strategies are intuitive
but have no empiric evidence such as volume
regulation, dry swallow, or sequential swallo-
wing for swallowing apraxia. Other strategies
have only indirect evidence such as 3-second
bolus hold.1 Finally, other compensations have
direct evidence with some strategies having
stronger empiric findings (e.g., chin tuck for
airway invasion before and during the swal-
low43,44 when the pooled material is in the
valleculae45 and effortful swallow for valleculae
residue due to reduced base of tongue (BOT) to
posterior pharyngeal wall [PPW] contact),46,47
while the evidence for other strategies is less
strong (e.g., chin tuck for valleculae residue48
and carbonation).49 See Table 2 for a list of
compensatory strategies.
Rehabilitation
Rehabilitative treatment is completed outside
of mealtime. While foods may be used during
rehabilitation exercises, they are not used for
nutritional purposes. Traditionally, rehabilita-
tion has focused on strength training. Other
types of rehabilitation, such as skill training and
central and peripheral modulation, are being
investigated. While some rehabilitation treat-
195
ments describe a specific regimen (e.g., expira-
tory muscle strength training [EMST],50
Shaker exercise,51 lingual resistance),52 the
majority of exercises do not, which makes it
difficult for the clinician to prescribe an effec-
tive dose.
As with compensation, the quality of the
evidence varies across each rehabilitation tech-
nique. Many studies target sign (residue, aspi-
ration) as the outcome and not the underlying
impairment (e.g., increased BOT to PPW
contact); both should be evaluated. For some
treatments, only immediate effects following
rehabilitation are reported (e.g., thermal-tactile
application)53 or investigators have studied only
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immediate effects (e.g., Masako maneuver),54
or results following short-term intervention
duration (e.g., effortful swallow55 and Mendel-
sohn maneuver).56 While initially testing in
healthy adults is beneficial to identify any
positive or negative effects (e.g., chin tuck
against resistance57 or recline exercise58), fol-
low-up studies in patient populations are criti-
cal. Three rehabilitative treatments (Shaker
exercise,51 lingual resistance exercise,59 and
EMST50,60) have been studied in disordered
populations with reported positive long-term
biomechanical and clinical effects. Even though
lingual resistance is suggested to improve oral
and pharyngeal tongue movement and strength,
only oral tongue pressures have been evaluated.
See Table 3 for a list of rehabilitative strategies.
Oral Hygiene
Oral hygiene should be part of the management
plan in all patients with stroke-related dyspha-
gia. It is well known that factors common in
patients following stroke such as decreased
mobility and dependence in eating and dental
hygiene are related to the development of
pneumonia.25 Systematic reviews concerning
the implementation of oral hygiene interven-
tions in nursing home facilities have identified
positive results in reducing morbidity and mor-
tality.61,62 Based on these reviews, brushing
teeth following meals, daily denture cleaning,
and weekly professional oral health care are
suggested; however, the optimal regime of oral
care is unclear as frequency and duration of
tooth brushing varied across studies.
 196
Table 2 Compensatory Strategies
Compensation Swallowing sign Stroke-related considerations

Self-regulated or sequential - Swallowing apraxia - Volume size with patients who are impulsive
swallowing - Ensure no aspiration with increased volume
Volume regulation - Pharyngeal pooling with/without airway invasion before or - Can be implemented with individuals with cognitive and/or
during the swallow comprehension impairment with commercially available
devices
- If devices are unavailable, these individuals will require direct
supervision
3-s bolus hold - Discoordinated oral transfer - Individuals with cognitive and/or comprehension impairment
- Pharyngeal pooling with/without airway invasion before or will require direct supervision
during the swallow
Chin tuck - Pharyngeal pooling with airway invasion before or during the - Individuals with cognitive and/or comprehension impairment
swallow will require direct supervision
- Airway invasion during the swallow due to reduced supra-
glottic closure
- Valleculae residue with/without airway invasion after the
swallow
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3

Carbonation - Pharyngeal pooling with/without airway invasion before or - Individuals with cognitive and/or comprehension impairment
during the swallow will require direct supervision
2019

- Pharyngeal residue with/without airway invasion after the

Thickened liquids
Breath hold maneuvers
swallow
- Airway invasion before or during the swallow
- Airway invasion before and during the swallow
- Monitor hydration status
- Consider small volumes of water for pleasure; volume
regulation devices or direct supervision may be required
- Complex strategy; must have good comprehension and
memory to complete
- Consider potential for fatigue in elderly or deconditioned
patients

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Table 2 (Continued)
Compensation Swallowing sign Stroke-related considerations
- Consider duration of pooling prior to airway invasion before
implementing
- Risk of cardiac arrhythmias in stroke patients64
Dry swallow - Pharyngeal residue - Easy to train and implement
- Individuals with cognitive and/or comprehension impairment
will require direct supervision to complete
Cyclic ingestion - Pharyngeal residue - Easy to train and implement
- Individuals with cognitive and/or comprehension impairment
will require direct supervision to complete
Head turn
To weaker side Unilateral pyriform sinus residue - Individuals with cognitive and/or comprehension impairment
To either side Bilateral pyriform sinus residue will require direct supervision to complete
Effortful swallow - Vallecular residue - Individuals with cognitive and/or comprehension impairment
will require direct supervision to complete
- Consider potential for fatigue in elderly or deconditioned
patients
Mendelsohn maneuver - Pyriform sinus residue - Complex maneuver to train, even for individuals with good
comprehension and cognition
- Individuals with cognitive and/or comprehension impairment
will require direct supervision to complete
- Consider potential for fatigue in elderly or deconditioned
patients
CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
197

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198 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

Table 3 Rehabilitation Strategies

Exercise Underlying impairment Stroke-related considerations

Thermal-tactile application - Delayed initiation of pharyngeal
swallow
Lingual resistance exercises - Reduced orolingual control and
strength
- Reduced BOT-PPW contact
Masako maneuver - Reduced BOT-PPW contact
- As multiple sessions are required, care-
giver will need to be trained to facilitate
completion in individuals with cognitive or
comprehension impairment or individuals
with dominant side hemiparesis
- Visual feedback with external device such
as the IOPI may increase participation in
individuals with cognitive or comprehen-
sion deficits
- Individuals who are edentulous and
without dentures will have increased diffi-
culty completing exercise

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Effortful swallow
EMST
Mendelsohn maneuver
Shaker exercise
CTAR
- Reduced base of tongue
retraction
- Reduced laryngeal elevation
- Reduced volitional cough
strength
- Reduced UES opening
- Reduced UES opening
- Reduced UES opening
- SLP may need to hold patient’s tongue
for those with cognitive or comprehension
deficits
- Using sEMG visual feedback may facili-
tate implementation in patients with com-
prehension or cognitive impairment
- As multiple sessions are required, care-
giver will need to be trained to facilitate
completion in individuals with cognitive or
comprehension impairment
- Complex exercise and difficult to teach for
individuals with comprehension or cogni-
tive impairment even when using sEMG
visual feedback
- Easy to demonstrate, for patient to
imitate, and for clinician to manipulate the
body for individuals with comprehension
or cognitive deficits
- As multiple sessions are required, care-
giver will need to be trained to facilitate
completion in individuals with cognitive or
comprehension impairment
- Most individuals, especially those who are
deconditioned, will not be able to com-
plete maximum duration or repetitions
initially, so will extend past recommended
6 wk
- For patients on tube feeding, ensure that
exercise is not completed within 1 h
following feeding
- Easy to demonstrate, for patient to
imitate, and for clinician to manipulate the
body for individuals with comprehension
or cognitive deficits
 CLINICAL DECISION MAKING IN PATIENTS WITH STROKE-RELATED DYSPHAGIA/FELIX ET AL
Table 3 (Continued)
Exercise Underlying impairment
Recline exercise - Reduced UES opening
Wada exercise - Reduced UES opening
Abbreviations: BOT, base of tongue; CTAR, chin tuck against resistance; EMST, expiratory muscle strength training;
IOPI, Iowa Oral Performance Instrument; PPW, posterior pharyngeal wall; sEMG, surface electromyography; SLP,
speech–language pathologist; TMJ, temporomandibular joint; UES, upper esophageal sphincter.
Implementation of an oral hygiene pro-
gram to reduce risk of pneumonia is suggested
in the AHA/ASA guidelines for management
of acute ischemic stroke.63 While nursing staff
frequently assumes the burden of completing
dental care, multidisciplinary collaboration bet-
ween nursing, speech pathology, occupational
therapy, and dental hygiene would appear to be
most appropriate to develop and implement
effective training and adherence to an oral
care program for patients following stroke.
CASE SCENARIO
LB, a 54-year-old male patient with history of
obesity and insulin-dependent diabetes mellitus
type 2, was admitted to general hospital with
complaint of left-sided weakness and slurred
speech for 1 day. His MRI scan revealed a right
middle cerebral artery ischemic stroke. Speech–
language pathology was consulted for dysphagia
evaluation as the patient was NPO following a
positive nursing-administered swallowing
screen. Prior to the stroke, LB consumed
regular solids with thin liquids at home with
no history of dysphagia.
The informal cognitive screen during the
CSE revealed disorientation, impaired short-
term memory, impulsivity, reduced insight
into deficits, and left neglect. Cranial nerve
assessment revealed reduced left labial asym-
metry at rest and with extension as well as
decreased ROM and strength (facial cranial
nerve). Weak volitional cough was identified,
199
Stroke-related considerations
- Easy to demonstrate, for patient to
imitate, and for clinician to manipulate the
body for individuals with comprehension
or cognitive deficits
- Easy to demonstrate, for patient to
imitate, and for clinician to manipulate the
body for individuals with comprehension
or cognitive deficits
- Avoid in individuals with TMJ issues pain
with jaw opening
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along with left lingual asymmetry on protru-
sion with decreased ROM and strength
(hypoglossal cranial nerve). The swallowing
portion of the CSE was completed with trials
of water (5 mL, 10 mL, self-regulated cup
sip), applesauce, and cheese crackers. LB
exhibited impulsivity with oral trials charac-
terized by not waiting for prompts, eating
quickly, and poor control of volume. Oral
phase dysphagia was evident characterized
by impaired bolus preparation with prolonged
and inefficient mastication of solids, reduced
bolus cohesion with oral residue present on
left lingual/dental surface and buccal space,
and prolonged oral transit time with solids.
Coughing was evident in both trials of self-
regulated cup sip; however, LB appeared
unconcerned as he attempted to continue
drinking the water. Larger liquid volumes
were not administered.
A VFSS was completed later that day with
the following trials tested: thin liquid Varibar
barium (5 mL, 10 mL, self-regulated cup sip),
nectar thick Varibar barium (self-regulated cup
sip, sequential swallowing), Varibar barium
pudding, and a barium pudding-coated cracker.
The oral phase was noted to be the same as
during the CSE with the addition of reduced
orolingual control for thin liquids resulting in
pyriform sinus pooling and aspiration before
the swallow (weak cough but no clearing) with
the self-regulated cup sip trials. Given cognitive
deficits, 3-second bolus hold, and chin tuck
were not attempted as compensatory strategies.
200 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
Nectar thick liquid, however, was attempted
and proved successful in preventing airway
invasion during self-regulated cup sip and
sequential swallowing. During the pharyngeal
phase, LB exhibited decreased BOT retraction
yielding moderate valleculae residue and redu-
ced UES opening due to decreased anterior
hyolaryngeal elevation yielding moderate bila-
teral pyriform sinus residue with semisolids and
the masticated solid. The residue did not build
up with subsequent swallows.
The SLP recommended nectar thick liquids
(International Dysphagia Diet Standardization
Initiative [IDDSI] level 2; www.iddsi.org) and
minced and moist solids (IDDSI level 5). Super-
vision during meals to regulate rate of ingestion
was recommended as well as supervised 10 mL
water volumes using a commercially available
cup for pleasure. LB participated in the occupa-
tional therapy feeding program during lunch,
and nursing support staff or family members
were available to supervise breakfast and dinner.
Rehabilitation recommendations included lin-
gual resistance exercises using the IOPI to
provide visual feedback to improve oral tongue
strength, the Masako maneuver and effortful
swallowing to also increase BOT to PPW
contact, EMST to facilitate cough strength,
and the Shaker exercises to facilitate anterior
hyolaryngeal elevation. LB’s family was taught
the exercises, so they could complete the neces-
sary trials outside of his twice-daily therapy
sessions.
LB was transferred to acute rehab on day 4
and continued to receive twice daily swallowing
and cognitive therapy. Therapy staff and family
provided oral hygiene after every meal. A repeat
VFSS was completed during week 3 and revea-
led improvement in mastication, orolingual
control, BOT to PPW contact, and UES open-
ing. No aspiration of liquids was noted, and
pharyngeal residue was minimal. Soft and bite-
sized solids (IDDSI level 6) and thin liquids
(IDDSI level 0) were recommended along with
continued supervision to monitor impulsive
behavior during mealtime.
FINANCIAL DISCLOSURES
C.C.F. receives salary support from Memorial
Hermann Health System.
2019
M.E.J. receives salary support from the Uni-
versity of Houston and Memorial Hermann
Health System.
S.K.D. receives salary support from the Uni-
versity of Houston, and royalties from Plural
Publishing and MedBridge.
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