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Nutrition and Dysphagia Considerations in Function Based Rehabilitation

Original Editor - Ewa Jaraczewska based on the course by Ansunette Pelser

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Dysphagia is a condition which affects a person's ability to prepare, form, and successfully and safely swallow a bolus of food or liquid -- Ansunette Pelser, Speech and Language Therapist [1]

Dysphagia, or difficulty swallowing, can be caused by a range of conditions, including stroke, brain injury, Parkinson's, motor neuron disease, dementia, intubation, and head and neck cancers. Healthy older adults may also experience age-related swallowing issues, known as presbyphagia.[1]

There are three phases of swallowing: the (1) oral phase, (2) pharyngeal phase and (3) oesophageal phase. Dysphagia may occur during any of these phases. This article focuses on oropharyngeal dysphagia, which affects the first two phases of swallowing. Oesophageal dysphagia affects the third phase of swallowing and requires a referral to a gastroenterologist.[1]

Oropharyngeal dysphagia leads to various complications, including malnutrition, dehydration, and pneumonia. Individuals with oropharyngeal dysphagia may require feeding tubes, experience extended hospital stays and have poorer outcomes. It can lead to readmissions and ultimately result in patients being transferred to rehabilitation or nursing facilities instead of returning home.[2] Health-related quality of life also reduces as dysphagia symptom severity increases.[3] Early detection and treatment of dysphagia is crucial to reduce illness, prevent complications, and shorten hospital stays.[4]

This article highlights the difficulties patients might face in meeting their nutritional needs because of oropharyngeal dysphagia and describes how healthcare professionals, families, and caregivers can best support these patients. Additionally, it explores when and to whom to refer patients with swallowing difficulties.

Relationship Between Dysphagia and Quality of Life

Beyond the physical consequences, like aspiration and malnutrition, oropharyngeal dysphagia can have psychological effects, including inducing anxiety or panic during meals. Its impact on mealtimes is significant, as meals are important social events. They can foster social connections, create positive emotions and promote dignity.[3]

While interventions for dysphagia support nutrition, improve swallowing and minimise health risks, they can, like the condition itself, impact a person's quality of life and social participation.[1] For instance, while enteral feeding enhances physical health, it can increase feelings of social isolation. Texture-modified diets increase safety, but they may reduce social participation in meals and limit a person's enjoyment of food.[5] Modified foods may lack visual appeal, which further limits enjoyment.[5] Individuals with dysphagia may feel nervous about ordering food or eating in social settings. This may influence whether or not they attend social events. Other people's perceptions and consideration of their needs can also impact their overall quality of life.[5]

Healthcare professionals must understand the multifaceted impacts of oropharyngeal dysphagia beyond physical health. Clinicians must not assume that physical improvements automatically equate to a better quality of life. Open communication is essential to tailoring interventions that prioritise quality of life and psychosocial well-being. Additionally, healthcare providers should empower individuals with dysphagia to advocate for themselves to ensure they are served appropriate food at mealtimes.

Anatomy and Physiology of Swallowing

As mentioned, the three phases of swallowing are the oral, pharyngeal, and oesophageal phases. The first two phases are relevant to oropharyngeal dysphagia and are discussed below.

For more detailed information on the anatomy and physiology of swallowing, please read this optional article: Anatomy and Physiology of Swallowing.

Oral Phase

The first phase of swallowing is the oral phase (see Figure 1). The oral phase includes the oral preparatory phase (chewing and bolus formation) and the oral transit phase (moving the bolus back). Weakness or lack of control in the oral structures (e.g. lips, cheeks, jaw, tongue, and hard or soft palate) can affect a person's ability to form, maintain and propel a bolus.[1]

Figure 1. Swallowing: oral phase.
Figure 2. Swallowing: pharyngeal phase.

Pharyngeal Phase

The pharyngeal phase of swallowing (see Figure 2) is a rapid process involving the movement of food from the upper oesophageal sphincter to the oesophagus. The airway must be protected during this phase.

Swallowing problems during the pharyngeal phase include failed initiation of swallowing or compromised muscle function. One or both of these impairments can lead to aspiration.

"Aspiration happens when food, liquid, or other material enters a person’s airway and eventually the lungs by accident. It can happen as a person swallows, or food can return from the stomach."[6]

Aspiration can be overt (with coughing) or silent (without coughing). Individuals with silent aspiration have an increased risk of developing aspiration pneumonia because swallowing difficulties may go unnoticed and they do not have access to the protective reflexes of coughing.[1]

Signs and Symptoms of Dysphagia

Signs and symptoms associated with dysphagia include: coughing during or after eating (i.e. overt aspiration), a wet or gurgly sounding voice, recurrent chest infections, drooling, having difficulty keeping food in the mouth and forming a bolus, nasal regurgitation, choking, eyes watering when swallowing, frequent throat clearing or repetitive swallows, hoarse voice, dysarthria, and unclear or nasal speech. These signs and symptoms can lead to reduced food intake, weight loss, dehydration, and malnutrition.[7][1]

Assessment of Dysphagia

Accurate and timely diagnosis of dysphagia in at-risk older adults is essential. Instrumental tests are the best way to identify oropharyngeal dysphagia. The gold standard tests are Flexible Endoscopic Evaluation of Swallowing (FEES) (see Figure 3) and Videofluoroscopic Swallowing Study (VFSS), also called Modified Barium Swallow (MBS) (see Figure 4).[8] There is also a range of bedside swallowing assessments to identify overt or visible symptoms of dysphagia. However, research suggests that these non-instrumental assessments may miss up to 50% of patients with silent aspiration.[9]

Figure 3. Fibreoptic endoscopic evaluation of swallowing (FEES).
Figure 4. Video fluoroscopic swallowing study.

If you would like to learn more about the dysphagia assessment, please see: Assessment of Dysphagia.

Multidisciplinary Team Approach in the Treatment of Dysphagia

Speech and language therapists collaborate closely with the multidisciplinary team to manage individuals with oropharyngeal dysphagia. This team may include dietitians, occupational therapists, physiotherapists, physicians, and nurses.[1]

Dietitians work with speech and language therapists to guarantee patients receive proper nutrition, considering their eating abilities. Dietitians evaluate nutritional requirements, track food intake, develop meal plans that accommodate dietary needs and swallowing difficulties, and oversee foodservice personnel who prepare the meals.[10]

Occupational therapists may work with patients on their ability to feed themselves. How we feed ourselves can significantly impact the oral preparatory phase of swallowing. For instance, a person who takes a very large portion of food may be unable to adequately chew it. People who can successfully feed themselves often have an improved oral preparatory phase of swallowing, as they can control the amount of food or liquid they take. Occupational therapists may also recommend adapted feeding tools to enhance independence with feeding. Example tools are shown in Figures 5, 6 and 7.

Figure 5. Scooper bowl plate.
Figure 6. Offset spoon.
Figure 7. Universal cuff.

Physiotherapists can advise on proper positioning and play an important role in monitoring and maintaining a healthy respiratory system, which is critical for people at risk of aspiration pneumonia.

Physicians work closely with speech and language therapists, especially when considering alternative feeding methods. Decisions regarding percutaneous endoscopic gastrostomy tube (PEG) placement are made collaboratively with the physician. These decisions must consider the patient's discharge environment to ensure safe and manageable tube feeding at home.

Nursing staff are vital in supporting patients with alternative feeding methods. They also provide education to families and caregivers on the management and care of nasogastric and percutaneous endoscopic gastrostomy tubes. They are invaluable during swallowing therapy, as they provide crucial observations on how patients manage during meals.

Speech and Language Therapy Interventions in Dysphagia

Speech and language therapists use a range of strategies to manage dysphagia, including (1) dietary modifications, (2) compensatory techniques, (3) swallowing therapy exercises and (4) sensory stimulation.

Dietary modification: speech and language therapists identify food textures patients can manage. For example, a patient who struggles to form a bolus might be given yoghurt instead of water. A puréed diet and thickened liquids may enhance swallowing ease and reduce aspiration risk until muscle strength improves. An ongoing collaboration with dietitians ensures adequate nutrition throughout treatment, particularly as patients progress and their ability to tolerate different food consistencies changes.

There is no standard definition of the ideal food texture for people with dysphagia.[11] However, the International Dysphagia Diet Standardisation Initiative (IDDSI) offers an eight-level (0-7) system to classify alimentary liquid and food; a syringe-based flow test is used for liquids (levels 0-4) while the fork pressure test is used for solids (levels 3-7).[11] Due to their slower flow, thicker consistencies like pastes and purées are often recommended for individuals with dysphagia, as they allow more time for safe swallowing. Foods that are softer, more uniform, easier to chew, and more elastic may require less oral effort during swallowing.[12]

Compensatory strategies, such as the chin tuck manoeuvre or intentional throat clearing after swallowing, are used to increase airway protection.[1]

Manual swallowing therapy exercises can be used cautiously and by trained professionals after consultation with the multidisciplinary team. These exercises aim to increase the strength and range of motion of the muscles associated with swallowing. More information on exercises for dysphagia and examples of oromotor exercises are available in this optional article: Dysphagia Rehabilitation Management.

Sensory stimulation can be used for patients with sensory deficits that delay the onset of swallowing. This includes using boluses with enhanced sensory properties (e.g., very sour or cold items).

Please remember that there is no one-size-fits-all approach—management will vary based on the person -- Ansunette Pelser, Speech and Language Therapist [1]

Final Considerations

Dysphagia has a significant impact on patients and their families. Ensuring safe feeding can enhance the quality of life of people with dysphagia and their family unit. Here are some key points to remember when working with people with oropharyngeal dysphagia:[1]

  • speech and language therapists can work on swallowing even for people with enteral feeding
  • for people with percutaneous endoscopic gastrostomy (PEG) tubes, "pleasure feeding" with small amounts of preferred foods and the Frazier Free Water Protocol can be considered, but their oral hygiene must be impeccable
  • oral health is essential to minimise bacterial aspiration
  • use supportive chairs or elevate patients for upright eating
  • patients should remain upright or in a semi-Fowler position of around 45 degrees for at least 30 minutes after eating
  • consider how to adjust a person's diet before total food restriction
  • encourage non-food-related social activities for families

Conclusion

Swallowing disorders have a significant impact on the lives of people with dysphagia. Providing safe feeding methods can improve the quality of life for both patients and their families. Optimal management requires early detection and multidisciplinary collaboration. Advocating for instrumental assessments and further training for speech and language therapists will help improve diagnosis and management.

Resources

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Pelser A. Nutrition and Dysphagia Considerations in Function Based Rehabilitation Course. Physiopedia Plus, 2025.
  2. ↑ Rivelsrud MC, Hartelius L, Bergström L, Løvstad M, Speyer R. Prevalence of Oropharyngeal Dysphagia in Adults in Different Healthcare Settings: A Systematic Review and Meta-analyses. Dysphagia. 2023 Feb;38(1):76-121.
  3. ↑ 3.0 3.1 Bendsen BB, Jensen D, Westmark S, Krarup AL, Riis J, Melgaard D. The Quality of Life in Citizens with Oropharyngeal Dysphagia-A Cross-Sectional Study. J Clin Med. 2022 Jul 20;11(14):4212.
  4. ↑ Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalised patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010 Aug;136(8):784-9.
  5. ↑ 5.0 5.1 5.2 Smith R, Bryant L, Hemsley B. The true cost of dysphagia on quality of life: The views of adults with swallowing disability. Int J Lang Commun Disord. 2023 Mar;58(2):451-466.
  6. ↑ Aspiration. The Causes and Complications You Can Help Manage. Available from https://www.dshs.wa.gov/sites/default/files/DDA/dda/documents/Aspiration.pdf [accessed 16.5.2025].
  7. ↑ Panara K, Ramezanpour Ahangar E, Padalia D. Physiology, Swallowing. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK541071/ [last access 16.5.2025]
  8. ↑ Lim HJ, Lai DK, So BP, Yip CC, Cheung DSK, Cheung JC, Wong DW. A Comprehensive Assessment Protocol for Swallowing (CAPS): Paving the Way towards Computer-Aided Dysphagia Screening. Int J Environ Res Public Health. 2023 Feb 8;20(4):2998.
  9. ↑ Jamróz B, Sobol M, Chmielewska-Walczak J, Milewska M, Niemczyk K. The risk factors for silent aspiration: A retrospective case series and literature review. Int J Lang Commun Disord. 2024 Jul-Aug;59(4):1538-1552.
  10. ↑ Kim D, Lee KE. Nutrition Care Management Practices for In-Patients with Dysphagia in Korean Clinical Settings. Clin Nutr Res. 2019 Oct 29;8(4):272-283.
  11. ↑ 11.0 11.1 Ismael-Mohammed K, Bolivar-Prados M, Laguna L, Clavé P. Measuring the Rheological and Textural Properties of Thick Purees Used to Manage Patients with Swallowing Disorders. Nutrients. 2023 Aug 28;15(17):3767.
  12. ↑ Wang X, Rong L, Shen M, Yu Q, Chen Y, Li J, Xie J. Rheology, Texture and Swallowing Characteristics of a Texture-Modified Dysphagia Food Prepared Using Common Supplementary Materials. Foods. 2023 Jun 6;12(12):2287.
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