Stroke is a leading cause of disability and death worldwide (Lindsay et al., 2014). In the U.S., someone has a stroke every 40 seconds, adding up to over 750,000 events each year (Tsao et al., 2023).
As a speech therapy professional, this means that you’ll very likely work with this population.
In this article, you’ll learn the 6 steps of getting started with your first stroke patient.
To save time and improve your SLP skills, visit our shop and online course for step-by-step guides to assessing and treating all your first diagnoses.
Your First Stroke Patient: What To Expect
The symptoms you may see in your very first stroke patient will vary widely.
Their speech, language, cognitive, and swallowing strengths and weaknesses will depend on the brain lesion site, extent of injury, age, comorbidities, and other factors.
When possible, prepare by coordinating with the multidisciplinary team before your assessment. Plan to consult weekly with active members of the team, such as physical therapy, occupational therapy, a dietitian, neurology, and/or respiratory therapy.
Speech Therapy After A Stroke: Assessment
A speech therapy assessment after a stroke may include:
- Language assessment (expressive and receptive language)
- Swallowing assessment
- Motor-speech assessment (dysarthria, apraxia)
- Cognition assessment (memory, attention, visual neglect, executive functioning)
- Voice assessment
- Fluency assessment
See the Evaluation Pack for 5-star rated informal speech therapy assessments.
1. Choose An Assessment
So how do you decide what areas to assess in a patient who had a stroke? Start with a chart review
If your patient is referred directly from the emergency room and you’re the first SLP to assess them, be ready to assess and screen multiple domains.
Check Brain Imaging
One way to determine which assessment to choose is by reviewing their brain imaging:
- What area(s) of the brain was injured? In general, a left hemisphere injury may mean aphasia or other speech and language deficits. While a right hemisphere injury may result in issues with pragmatics and cognitive-communication skills (including attention, memory, executive functioning, visual neglect, and/or awareness of deficits; American Speech-Language-Hearing Association, n.d.).
- What is the extent of the brain injury?
Check The Physician’s Notes
Check the admitting physician’s notes for mention of neurological deficits. If you read notes identifying facial droop, signs of dysphagia, slurred speech, or language deficits, this can help you determine what to assess.
For example, if their notes identify facial droop and/or slurred speech, plan to complete both a clinical swallow evaluation and dysarthria assessment.
Scan for any diagnoses that may indicate a possible swallowing disorder, such as abnormalities of the mouth, throat, central nervous system, cranial nerves, respiration, and/or cardiovascular system. If any of these are present, you’ll need to complete a clinical swallow evaluation.
For more help, read Speech Therapy For Dysphagia: How To Get Started
What else to look for in a chart review:
- Primary diagnosis or reason for admission
- Past medical history
- Labs, other imaging, vital signs
- Allergies
- Current diet level
- History of receiving speech therapy and speech therapy notes (deficits noted, goals, diet, recommendations)
- Precautions (hip precautions, isolation precautions, etc.)
- Nerve or muscle damage
Speech Therapy Screens After A Stroke
If there isn’t enough medical information in the chart for you to choose the right assessment, don’t worry! Use a screen.
A screen is a quick tool that identifies if a deficit is likely present and warrants (or rules out) a full assessment.
You can use screens to determine your patient’s general strengths and weaknesses in motor speech, language, cognition, voice, fluency, and/or swallowing abilities.
Some helpful speech therapy screens when assessing strokes include:
- Yale Swallow Protocol (swallowing)
- ASHA’s EAT-10 Assessment (swallowing)
- MoCA (cognitive-communicaiton)
- SLUMS (cognitive-communication)
- MAST (aphasia)
- Voice-Handicap Index (voice)
- Cancellation test (visual neglect)
- Xerostomia questionnaire (swallowing)
Now it’s time to gather your screen and assessments and meet the patient! Be sure to sanitize and don the appropriate personal protective equipment.
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2. Interview The Patient & Care Partner
Confirm the patient’s name and date of birth and ask how they want to be addressed (name, nickname).
Verify details of their medical history, symptoms, and the reason for your assessment. Briefly describe how your assessment will go.
Ask questions to understand their personal goals, needs, desires, and preferences. This will help guide your decision-making and recommendations.
During the interview, you may notice that the patient has cognitive, language, voice, swallowing, fluency, and/or motor-speech deficits that weren’t noted in their chart. Address these later in the assessment or during a follow-up treatment.
3. Complete An Oral Motor Exam (OME)
If your patient has any red flags for swallowing difficulties and/or possible motor-speech deficits (nerve damage, etc.), complete an OME.
Observe strength, range of motion, speed, and symmetry of the following:
- Mandible (CN V): at rest, open (pressure), close (pressure), lateralization, protrusion, retraction
- Lips (CN VII): at rest, protrusion, retraction, repetitive protrude/retract, puff cheeks, strength, sensitivity (CN IX)
- Tongue (CN XII): at rest, protrusion (strength), stick up (strength), stick down (strength), lateralization (strength), retraction (CN V, XII), strength, lick teeth, lick lips
- Velum: at rest (CN IX), prolonged “ah” (CN X), repetitive “ah” (CN X)
- Reflexes (CN IX, X): gag, faucial arches
Read How To Do An Oral Motor Exam for more details.
If your patient demonstrates decreased strength, range of motion, and/or asymmetry of the orofacial structures during the OME, proceed with a clinical swallow examination. They will also likely benefit from a dysarthria assessment.
4. Complete Appropriate Assessments And Screens
Complete the appropriate assessments based on your chart review findings, patient/care partner interview, and OME results.
Again, you may assess or screen swallowing, language, cognition, motor speech, voice, and/or fluency.
What do you do if you suspect that your patient has more than one speech therapy-related issue, like dysphagia and dysphonia?
Since your time is limited, first focus your assessment on the major weaknesses that most affect their safety, quality of life, and ability to communicate.
For example, based on the chart review, patient interview, and screens, you make your best educated guess that your patient’s swallowing is more severely impacted than their voice. So you decide to focus on assessing dysphagia for now.
For more guidance on assessments, read our Complete Guide To Adult Speech Therapy Assessments.
5. After The Assessment: Educate & Make Referrals
After completing the assessments, share your recommendations with the patient and their care partners.
Educate them about the deficits your assessment identified and share appropriate strategies (i.e., swallowing strategies or breathing strategies).
See our shop for premade materials, handouts, and diagrams for speech therapy patients.
Patients often have a large multidisciplinary team after experiencing a stroke. Be ready to refer out if they have concerns outside of your scope of practice. Common referrals after a stroke include:
- Gastrointestinal specialist: Esophageal or digestion issues
- Otolaryngologist. Head, neck, ear, throat concerns
- Neurologist. Neurological concerns
- Neuropthamologist or ophthalmologist, optometrist. Vision and visuospatial concerns
- Audiologist and/or otolaryngologist. Hearing concerns
- Other referrals may include physical therapist, occupational therapist, dietitian, cardiologist, respiratory therapist, psychologist, and others
6. Speech Therapy Treatment After A Stroke
If your patient is a candidate for speech therapy treatment, they will likely benefit from compensatory strategies and/or rehabilitative exercises.
For many patients, first plan to teach compensatory strategies. For example, a patient with slurred speech may benefit by speaking with a slower rate and open mouth. Or a patient with swallowing difficulties may decrease their risk of aspiration with smaller bites and sips.
Remember to focus treatment on how the changes in their abilities affect their quality of life. Keep their personal goals at the center of your treatment.
For example, your patient has severe dysphagia and mild dysphonia. Their goal is to continue having coffee with friends at their favorite cafe. You choose to focus treatment on working back up to thin liquids. You also spend time working on voice, so they can more easily converse with their friends.
Speech Therapy Exercises After A Stroke
There are many speech therapy exercises and treatments that can help patients recover after a stroke. Which ones you recommend will depend on each patient.
Here are a few evidence-based options:
Aphasia Exercises & Treatments:
- Naming therapy
- VNeST (Verb Network Strengthening Treatment)
- Semantic Feature Analysis
- Functional aphasia worksheets
Dysphagia Exercises & Treatments:
Cognitive Exercises & Treatments:
- Teach memory strategies
- External aids like calendar tasks for memory, attention, and problem-solving
- Lighthouse Strategy for visual neglect
- ADLs and IADLs for executive functioning
- Attention activities
- Improve awareness
Motor Speech & Voice Exercises & Treatments:
- Dysarthria exercises for articulation
- Integral Stimulation for apraxia of speech
- Breathing exercises
- Functional motor speech worksheets
More Speech Therapy Stroke Materials
Adult Speech Therapy Starter Pack
The Starter Pack is 900+ pages of print-and-go adult speech therapy worksheets, handouts, and templates.
Adult Speech Therapy Roadmap Course
The Adult Speech Therapy Roadmap is an online course that teaches you how to assess, treat, and document all major areas of adult speech therapy, from Day 1 to Discharge.
References
- American Speech-Language-Hearing Association. (n.d.). Right hemisphere Disorder [Practice portal]. Retrieved January, 2025. https://www.asha.org/Practice-Portal/Clinical-Topics/Right-Hemisphere-Disorder/
- Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
- Lindsay, P., Furie, K. L., Davis, S. M., Donnan, G. A., & Norrving, B. (2014). World Stroke Organization Global Stroke Services Guidelines and Action Plan. International Journal of Stroke. https://doi.org/10.1111/ijs.12371
- National Institute of Health and Care Excellence. (2023). Stroke rehabilitation in adults NICE guideline [NG236]. https://www.nice.org.uk/guidance/ng236.
- Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Beaton, A. Z., Boehme, A. K., Buxton, A. E., Commodore-Mensah, Y., Elkind, M. S. V., Evenson, K. R., Eze-Nliam, C., Fugar, S., Generoso, G., Heard, D. G., Hiremath, S., Ho, J. E., Kalani, R., … American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee (2023). Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation, 147(8), e93–e621. https://doi.org/10.1161/CIR.0000000000001123
- Wei, L., Shang, W., Nan, Y., Liu, Y., Yang, J., & Yang, K. (2025). Evidence Map of Clinical Practice Guideline Recommendations on Stroke Rehabilitation. American journal of physical medicine & rehabilitation, 104(2), 193–201. https://doi.org/10.1097/PHM.0000000000002413