April 21, 2023 1

Dysphagia:Management Approach in StrokeMarlís González Fernández, MD, PhD

Associate Professor

Physical Medicine and Rehabilitation

Disclosures

I have no conflicts of interest to disclose

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Outline

• Epidemiology

• Neural control

• Screening

• Evaluation

• Treatment

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Dysphagia

• Common after stroke

• Affects about 50% of stroke patients

• Improves within 7-14 days

• 11-13% still dysphagic at 6 months

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Consequences

• Malnutrition

• Dehydration

• Pneumonia

• Higher mortality

• Increased length of hospital stay

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Outcomes

• Formal dysphagia screen prevents pneumonia1

• Aspiration on VFSS associated with lower respiratory tract infection2-3

• Clinically unsafe swallow predictive of outcome including lower respiratory tract infection4

04/21/23 1 Hinchey et al., 2005; 2 Holas et al. 1994; 3 Kidd et al. 1995; 4 Smithard et al., 1998) 6

Location

• Brain stem stroke– Rostral medulla – Severe dysphagia– Less likely to improve

• Bilateral stroke– Pseudobulbar palsy– Recurrent strokes

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Procedure

• Screen

• Evaluate– Clinical evaluation– Instrumental Examination

• VFSS• FEES

• Treat

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Screening goal

Detect dysphagia and determine the possibility of aspiration (overt or silent) before developing:

Pneumonia

Dehydration

Malnutrition

Airway Obstruction

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Screening

• NPO until completed

• Screen as early as possible

• Trained personnel is critical

• Choose a standardized tool

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Screening Tools

1. Burke Dysphagia Screening Test (BDST)1

2. Standardized Swallowing Assessment (SSA)2

3. Timed tests of Hinds and Wiles3

4. Bedside swallow assessment (BSA)4

5. Toronto Bedside Swallowing Screening Test (TOR-BSST)©5

6. Clinical examination (CE) – any two of a list of clinical features6

04/21/231 DePippo et al. 1994; 2 Ellul et al. 1993; 3 Hinds and Wiles, 1998; 4 Smithard et al., 1996; 5 Martino et al., 2009; Daniels et al., 1997

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Screening Tools

They rely on:

1.A few clinical features

2.Swallowing water

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Clinical Examination(Screening)Positive if any two of the following clinical findings present:

1. Dysphonia

2. Dysarthria

3. Abnormal Gag

4. Abnormal Volitional Cough

5. Cough after swallow

6. Voice changes after swallow

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Test Std.Clinical

Eval.Sensory Water Se Sp

BDST VFSS Yes No 3oz Water swallow 88 22

SSA VFSS Yes No1. 5ml X 3

2. Cup drinking68 86

Timed Test

SymptomQuest.

Yes No1. 5-10 ml

2. 100-150 ml73 67

BSA VFSS/CE Yes No1. 5 ml X 3

2. 60 ml70 66

TOR-BSST©

VFSS Yes Yes1. 5ml swallow X 10

2. Cup sip 91.3 66.7

CE VFSS Yes No N/A 92 67

MMASA MASA Yes No N/A 93 86

Screening Tests Summary

Formal Clinical Evaluation

• Performed by specialist – Speech Therapist or SLP

• Clinical Assessment– Determine aspiration risk– Unable to detect silent aspiration

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Silent Aspiration

Aspiration without signs of material passage into the respiratory tract.

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Silent Aspiration

• Daniels et al. - 13/19 subjects aspirated silently

• Holas et al. - 53.5% of patients admitted for rehabilitation after stroke aspirated; 39% of those silently

• Kidd et al. – 8% of subjects aspirated silently

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Instrumental Evaluation

• Videofluoroscopic swallowing study (VFSS)

• Fiberoptic endoscopic evaluation of swallowing (FEES)

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When to obtain instrumental exam?

• Silent Aspiration is a concern

• Effective treatment program needs to be determined

• Deficit etiology is unclear

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VFSS

• Identify abnormalities of swallowing

• Determine the circumstances for safe swallowing

• Trials of therapeutic and compensatory maneuvers

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FEES

• Directly visualize the pharynx and larynx before and after swallowing.

• Identify aspiration and pharyngeal retention of food before or after swallowing.

• Cannot visualize during swallowing.• Cannot evaluate esophagus or sphincters.

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Principles of Therapy

• Therapy is directed at the underlying pathophysiology– Use therapeutic exercise to improve range

of motion, strength and coordination• “Swallowing is the best exercise for

swallowing”– Recreate the circumstances for safe and

efficient swallowing– Prevent complications

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Therapeutic interventions

• Swallowing Maneuvers

• Exercises

• Diet Modifications

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Swallowing Maneuvers

• Neck Flexion

• Head turn

• Head tilt

• Supraglottic swallow

• Mendelsohn Maneuver

• Effortful swallow

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Diet Modifications

• Thickened liquids– Nectar– Honey

• Solids– Chopped – Mechanical soft– Pureed

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Exercises

• Shaker Exercises

• Tongue strengthening

• Laryngeal elevation and vocal cord

adduction exercises

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Novel Therapies

• Neuromuscular electrical stimulation (NMES)

• Tongue strengthening devices

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