The Role of the Speech and Language Therapist in Dysphagia Management

The Speech and Language Therapist (SLT) — known in North America as a Speech-Language Pathologist (SLP) — is the specialist clinician with primary professional responsibility for the assessment, diagnosis, and management of dysphagia (swallowing disorders). Understanding what an SLT does in the context of dysphagia enables clinicians, nurses, care home staff, and family members to work more effectively with the service and to identify when referral is needed.

This article follows ASHA Practice Portal guidance on adult dysphagia and NICE CG162.

Scope of Practice

According to ASHA, SLTs hold the primary clinical responsibility for:

• Screening and identifying individuals who may have dysphagia
• Conducting comprehensive clinical and instrumental swallowing evaluations
• Diagnosing the nature and severity of dysphagia
• Planning, implementing and evaluating swallowing treatment
• Providing education and training to patients, carers and other healthcare providers
• Making appropriate referrals to other specialists as needed
• Participating in ethical decision-making around nutrition and feeding

In Hong Kong, SLTs are trained at the bachelor’s or master’s level and registered through the Hong Kong Association of Speech-Language Pathologists (HKASLP). They work across hospital, community, residential care, and private practice settings.

Assessment: What the SLT Evaluates

Case History

The SLT begins by establishing:

• Primary diagnosis and medical history
• Onset, duration and progression of swallowing difficulties
• Symptom description (coughing, choking, timing, bolus type)
• Current diet and hydration intake
• Weight history and nutritional status
• Medications affecting swallowing function
• Social history (who cooks, who assists with meals, care home or home-based)

Oral Mechanism Examination

The SLT examines:

• Facial and labial symmetry and movement
• Tongue strength, range of motion, and coordination
• Palatal elevation and velopharyngeal function
• Dentition and oral hygiene
• Voice quality and cough strength
• Secretion management

Clinical Swallowing Evaluation

A structured bolus trial across multiple food and liquid textures, using IDDSI-standardised consistencies. Observation for aspiration signs, oral residue, multiple swallows, and voice change. Pulse oximetry may be used as a supplementary measure.

Instrumental Assessment

For patients where clinical assessment is insufficient to characterise risk or guide management:

• FEES — fibreoptic endoscopic evaluation; bedside capable; visualises pharyngeal anatomy and laryngeal function directly
• VFSS — videofluoroscopy; shows all four swallowing phases; requires radiology suite

Prof. Karen Chan’s HKU Swallowing Research Lab has been a leading centre for instrumental assessment research and SLT training in Hong Kong, including training in both FEES and VFSS interpretation for Chinese food boluses.

Diagnosis and Grading

The SLT produces a diagnosis specifying:

• Which phase(s) of swallowing are impaired
• The nature of the impairment (e.g., delayed swallow initiation, reduced hyolaryngeal excursion, impaired pharyngeal clearance)
• The severity (using validated scales such as PAS for aspiration; DOSS or FOIS for functional feeding level)
• The bolus types and volumes that are safe versus unsafe

IDDSI Texture and Liquid Prescription

A central output of SLT dysphagia assessment is an IDDSI diet and liquid level recommendation:

• Food texture level: IDDSI Levels 3–7 (from Liquidised to Regular)
• Liquid thickness level: IDDSI Levels 0–4 (from Thin to Extremely Thick)
• Mixed consistency guidance (e.g., whether soups with solids are safe)
• Specific food avoidances (e.g., “no fibrous or stringy foods”; “no round, hard foods like grapes or nuts”)
• Volume and bolus size recommendations (e.g., maximum 5 mL per teaspoon)

The IDDSI prescription is communicated in writing to:

• The patient and family
• The care home kitchen
• The nursing team
• The dietitian (to ensure nutritional adequacy within the prescribed IDDSI level)
• The prescribing doctor (to advise on medication administration)

The IDDSI framework (2019) provides the global standard for all texture and liquid terminology.

Swallowing Rehabilitation

Where neural plasticity or muscle strengthening can improve swallowing function, the SLT implements a rehabilitation programme:

Exercise-Based Therapy

• Lingual strengthening (IOPI, spoon resistance)
• Shaker / CTAR (suprahyoid muscle strengthening)
• Mendelsohn manoeuvre (UOS opening)
• Effortful swallow (pharyngeal pressure)
• LSVT LOUD (for Parkinson’s disease)

Compensatory Strategies

• Chin-tuck and head rotation postures
• Double swallow technique
• Alternating food and liquid swallows
• Slow pacing with rest breaks during meals

Caregiver Training

Caregivers are trained in:

• Preparation of IDDSI-correct foods and liquids (including IDDSI testing methods)
• Safe feeding positioning and techniques
• Recognition of aspiration warning signs
• Emergency response to choking
• Oral hygiene protocols

Interdisciplinary Collaboration

SLTs work as part of a multidisciplinary team:

In Hong Kong residential care homes, effective SLT engagement requires coordination with the care home manager, kitchen staff, and family members — particularly regarding IDDSI implementation in the care home kitchen.

Ethical Dimensions

SLTs are routinely involved in complex ethical decisions around dysphagia:

• When does the aspiration risk from oral feeding outweigh the quality-of-life benefit?
• Should an individual with dementia and severe dysphagia receive a PEG tube?
• How should caregiver risk awareness be balanced against patient autonomy?

These decisions require multidisciplinary input and explicit patient (or proxy) participation. NICE guidance and ASHA ethical principles both emphasise that the least restrictive intervention should be the default, and that patient preferences must be central to management decisions.

References

1. American Speech-Language-Hearing Association. Adult Dysphagia Practice Portal. https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/
2. National Institute for Health and Care Excellence. Stroke Rehabilitation in Adults (CG162). https://www.nice.org.uk/guidance/cg162
3. IDDSI. The IDDSI Framework. https://www.iddsi.org/framework
4. Logemann JA, et al. (2015). Disorders of deglutition. Handbook of Clinical Neurology, 129, 465–487. PMID: 26315994