Speech Therapy For Dysphagia: How To Get Started

At least half of people with a stroke, traumatic brain injury, Parkinson’s disease, ALS, and other common diagnoses seen by speech therapy may have dysphagia (American Speech-Language-Hearing Association, n.d.) 

And up to 50% of acute patients over 70 years old have oropharyngeal dysphagia (Mateos-Nozal et al., 2020).

So how do you get started? 

In this article, you’ll learn the foundations of how to do speech therapy for dysphagia. For more help, you’ll also find links to in-depth treatment guides.

To save time and build confidence, visit our shop and online course for a step-by-step guide to assessing and treating all of your first diagnoses.

Complete A Clinical Swallow Evaluation

Once you receive the dysphagia referral, be ready to complete a Clinical Swallow Evaluation (CSE). 

A CSE is a comprehensive assessment of your patient’s swallowing abilities. It’s also the foundation of your dysphagia treatment plan.

There are 6 steps to a CSE, including:

• Chart review
• Patient/caregiver interview
• Oral-mechanism examination
• Food/liquid trials
• Making recommendations
• Education

You’ll find a brief description of each step below. For more help, read our step-by-step guide to Clinical Swallow Evaluations.

Dysphagia Assessment PDF

For a premade Clinical Swallowing Evaluation template, see the 5-star-rated Evaluation Pack. It includes a dysphagia assessment PDF made for speech therapy professionals.

Step 1: Chart Review

The first step of your clinical swallow examination is to review the patient’s medical chart to learn about their past and current medical history. Here’s what to make note of when reviewing their chart:

• Primary diagnosis or reason for admission
• Past medical history (related to dysphagia)
• Labs, imaging, vital signs
• Allergies
• Current diet level
• History of receiving speech therapy and speech therapy notes (goals, recommended diet, etc.)
• Precautions (hip precautions, isolation precautions, etc.)

Once you know why the patient was referred to speech therapy, ask their nurse if they’re awake and alert enough for a CSE. Also ask if they noticed any difficulties with swallowing, about their cognition, etc.

Next, it’s time to meet the patient! Be sure to sanitize and don the appropriate personal protective equipment.

Step 2: Patient/Caregiver Interview

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 evaluation. Briefly describe what your evaluation will look like.

Ask what foods or liquids they avoid or have difficulty swallowing. Ask how they take their medications (whole with water? In applesauce?)

It may be helpful to bring in swallowing surveys, such as the EAT-10, MASA, or PILL-5.

During the interview, you may notice that the patient has cognitive, language, voice, and/or motor-speech deficits. Address these later in the evaluation or during a follow-up treatment.

Step 3: Oral-Mechanism Examination

Before food or liquid trials, complete an oral-mechanism examination (OME). An OME includes:

• Cranial nerve exam
• Diadochokinetic rate and/or motor speech exam
• Assessing cough
• Checking other body functions (ability to walk, self-feed, etc.)

During the OME, you will observe strength, range of motion, and symmetry of the cranial nerves and oral-motor structures. Note any asymmetry, weakness, and red flags (hypernasality, lack of sensation). 

Refer to neurology, gastroenterology, or otolaryngology for underlying structural or neurological issues.

Read How To Do An Oral-mechanism Examination for a detailed OME.

Step 4: Food and Liquid Trials

Since you will assess eating and drinking, you’ll need food/liquid supplies. Check your facility’s nutrition room and/or kitchen for:

• Cups, straws, spoons/utensils
• Ice-chips
• Water
• Thin liquids (i.e. juice)
• Carbonated sugar-free beverage
• Puree textures (applesauce, pudding) 
• Minced and moist textures (cottage cheese, minced banana) 
• Soft and bite-sized textures (soft chopped-up meat with sauce, peaches)
• Regular texture (cereal bar, toast)​

Since every patient with dysphagia is different, each food and liquid trial will also vary. 

Always check if the patient had an instrumental assessment before presenting PO trials. And always complete adequate oral care before PO trials.

For more help, read our detailed guide to presenting food and liquid trials.

Step 5: Make Recommendations

After completing PO trials, it’s time to make your recommendations! You will recommend a diet/liquid level, swallowing strategies, swallowing exercises, an instrumental assessment, and/or make any necessary referrals.

Ask what your patient’s goals are in therapy. For example, what diet would they like to be on or hope to advance to?

Step 6: Educate

Educating your patients and their care partners is a vital part of your CSE. Provide handouts to better explain dysphagia, what you recommend, and swallowing strategies.

If your patient had or is planning to have an instrumental evaluation, use the results as a guide for what exercises and compensatory exercises to recommend.

Speech Therapy For Dysphagia: Treating Your First Patient With Dysphagia

If your patient is a candidate for dysphagia treatment, they will likely benefit from compensatory strategies and/or rehabilitative exercises.

Most dysphagia treatment includes a combination of both. 

Compensatory Strategies

Depending on the patient’s swallowing deficits, you may recommend compensatory strategies. 

These include modifications to the bolus, including altered diet textures and liquid consistencies (learn more about Dysphagia Diet Levels).

Other swallowing compensatory strategies include:

• Small bites and sips
• Single bite and/or sip at a time
• Alternating bites and sips
• No straws
• Chin tuck
• Head turn or tilt
• Swallow twice
• Eat and drink slowly
• Breath-hold and swallow (supraglottic)

See our shop for a complete list. 

You may need to recommend an instrumental evaluation to determine which strategies are effective for a particular patient (e.g., chin tuck or head turn/tilt). 

Rehabilitative Swallowing Exercises

Swallowing exercises are not one-size-fits-all. Each exercise targets a specific area of the swallowing mechanism that is weakened and impaired.

An instrumental assessment is the best way to decide which exercises to recommend for each patient.

Read Swallowing Exercises and Strategies to learn how to do dysphagia exercises.

More Dysphagia Resources

References

• American Speech-Language-Hearing Association. Adult Dysphagia. Retrieved November 10, 2024 from https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/
• Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Garand, K. L. F., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment Across the Life Span: The Clinical Swallow Evaluation. American journal of speech-language pathology, 29(2S), 919–933. https://doi.org/10.1044/2020_AJSLP-19-00063
• Mateos-Nozal, J., Montero-Errasquín, B., Sánchez García, E., Romero Rodríguez, E., & Cruz-Jentoft, A. J. (2020). High Prevalence of Oropharyngeal Dysphagia in Acutely Hospitalized Patients Aged 80 Years and Older. Journal of the American Medical Directors Association, 21(12), 2008–2011. https://doi.org/10.1016/j.jamda.2020.04.032
• Suiter, D. & Puntil, J. (n.d.) Screening and Bedside Swallow Evaluation Across the Continuum of Care. [Online course]. Medbridge. Retrieved from https://www.medbridge.com/educate/courses/screening-and-bedside-swallow-evaluation-across-the-continuum-of-care-jo-puntil-and-debra-suiter 
• Yang, S., Park, W., Min, K., Lee, Y. S., Song, J., Choi, S. H., Kim, D. Y., Lee, S. H., Yang, H. S., Cha, W., Kim, J. W., Oh, M., Seo, H. G., Kim, W., Woo, S., Park, J., Jee, S., Oh, J. S., Park, K. D., . . . Choi, K. H. (2023). Clinical Practice Guidelines for Oropharyngeal Dysphagia. Annals of Rehabilitation Medicine, 47(Suppl 1), S1. https://doi.org/10.5535/arm.23069