1. Dysphagia: Management Approach in Stroke
Marlís González Fernández, MD, PhD
Associate Professor
Physical Medicine and Rehabilitation
April 25, 2017

2. Disclosures
I have no conflicts of interest to disclose
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3. Outline Epidemiology Neural control Screening Evaluation Treatment
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4. 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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5. Consequences Malnutrition Dehydration Pneumonia Higher mortality
Increased length of hospital stay
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6. 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
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1 Hinchey et al., 2005; 2 Holas et al. 1994; 3 Kidd et al. 1995; 4 Smithard et al., 1998)

7. Location Brain stem stroke Bilateral stroke Rostral medulla
Severe dysphagia
Less likely to improve
Bilateral stroke
Pseudobulbar palsy
Recurrent strokes
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8. Procedure Screen Evaluate Treat Clinical evaluation
Instrumental Examination
VFSS
FEES
Treat
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9. Screening goal
Detect dysphagia and determine the possibility of aspiration (overt or silent) before developing:
Pneumonia
Dehydration
Malnutrition
Airway Obstruction
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10. Screening NPO until completed Screen as early as possible
Trained personnel is critical
Choose a standardized tool
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11. Screening Tools Burke Dysphagia Screening Test (BDST)1
Standardized Swallowing Assessment (SSA)2
Timed tests of Hinds and Wiles3
Bedside swallow assessment (BSA)4
Toronto Bedside Swallowing Screening Test (TOR-BSST)©5
Clinical examination (CE) – any two of a list of clinical features6
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1 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

12. Screening Tools They rely on: A few clinical features Swallowing water
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13. Clinical Examination (Screening)
Positive if any two of the following clinical findings present:
Dysphonia
Dysarthria
Abnormal Gag
Abnormal Volitional Cough
Cough after swallow
Voice changes after swallow
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Daniels et al., 1997

14. Screening Tests Summary
Std.
Clinical
Eval.
Sensory
Water Se Sp
BDST
VFSS
Yes No
3oz Water swallow 88 22
SSA
5ml X 3
Cup drinking 68 86
Timed Test
Symptom
Quest.
5-10 ml ml 73 67
BSA
VFSS/CE
5 ml X 3
60 ml 70 66
TOR-BSST©
5ml swallow X 10
Cup sip
91.3
66.7 CE
N/A 92
MMASA
MASA 93

15. Formal Clinical Evaluation
Performed by specialist
Speech Therapist or SLP
Clinical Assessment
Determine aspiration risk
Unable to detect silent aspiration
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16. Silent Aspiration
Aspiration without signs of material passage into the respiratory tract.
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17. Silent Aspiration Daniels et al. - 13/19 subjects aspirated silently
Holas et al % of patients admitted for rehabilitation after stroke aspirated; 39% of those silently
Kidd et al. – 8% of subjects aspirated silently
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18. Instrumental Evaluation
Videofluoroscopic swallowing study (VFSS)
Fiberoptic endoscopic evaluation of swallowing (FEES)
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19. When to obtain instrumental exam?
Silent Aspiration is a concern
Effective treatment program needs to be determined
Deficit etiology is unclear
Oral vs. pharyngeal vs. esophageal dysfunction and diagnoses.
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20. VFSS Identify abnormalities of swallowing
Determine the circumstances for safe swallowing
Trials of therapeutic and compensatory maneuvers
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21. 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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22. 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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23. Therapeutic interventions
Swallowing Maneuvers
Exercises
Diet Modifications
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24. Swallowing Maneuvers Neck Flexion Head turn Head tilt
Supraglottic swallow
Mendelsohn Maneuver
Effortful swallow
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25. Diet Modifications Thickened liquids Solids Nectar Honey Chopped
Mechanical soft
Pureed
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26. Exercises Shaker Exercises Tongue strengthening
Laryngeal elevation and vocal cord
adduction exercises
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27. Novel Therapies Neuromuscular electrical stimulation (NMES)
Tongue strengthening devices
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28. ?
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