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. 2025 Jul 25;32(8):e70307. doi: 10.1111/ene.70307

Gaps in Guidelines on Long‐Term Management Strategies for Post‐Stroke Dysphagia

Anel Karisik 1, Bendix Labeit 2, Alois Josef Schiefecker 1, Simon Sollereder 3, Oliver Galvan 4, Simone Graf 4, Stefan Kiechl 1,3, Michael Knoflach 1,3, Lukas Mayer‐Suess 1,✉
PMCID: PMC12290305  PMID: 40708460

ABSTRACT

Background

Post‐stroke dysphagia (PSD) is a frequent yet overlooked complication of stroke with significant implications for rehabilitation. While international guidelines provide structured recommendations for early screening and management, guidance on long‐term care remains inconsistent. This position paper synthesizes existing guidelines, identifies critical gaps, and highlights the need for standardized long‐term management strategies.

Methods

Guidelines on PSD management were identified through a two‐step approach. Fourteen guidelines were included from a previous systematic review (2014–2023), and two additional guidelines were identified through a systematic PubMed search (2014–2025). Inclusion criteria mandated guidelines of moderate‐to‐high quality (AGREE II assessment) that were published in peer‐reviewed journals and provided specific recommendations for managing PSD during acute, subacute, and chronic phases.

Results

Analysis of 10 moderate‐to‐high quality guidelines revealed strong consensus on acute‐phase screening and early interventions. All recommend dysphagia screening within 24 h of admission, with nine advising nil‐per‐os status until screening completion. There is consensus on instrumental assessments (videofluoroscopy, endoscopy), though application criteria vary. Management strategies include dietary modifications, nutritional support, oral health care, behavioral interventions, neurostimulation, and pharmacological therapies. While acute‐phase recommendations are well defined, structured long‐term follow‐up guidance remains limited, with only one guideline specifying reassessment intervals beyond hospital discharge.

Conclusion

The absence of standardized long‐term PSD management likely reflects limited availability of high‐quality evidence on long‐term care. Further research is needed to establish optimal reassessment intervals, high‐risk subgroups, and long‐term rehabilitation strategies to improve care for stroke survivors with persistent dysphagia.

Keywords: dysphagia, guidelines, long‐term care, recommendations, stroke

Gaps in Management Guidelines for Post‐Stroke Dysphagia.

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1. Introduction

Post‐stroke dysphagia (PSD) is a common complication of stroke, affecting up to 81% of patients during the acute phase (within the first week post‐stroke) [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]. It is strongly associated with adverse functional outcomes, including malnutrition, aspiration, pneumonia, mortality, reduced quality of life, and imposes a significant financial burden on the healthcare system [13]. While many patients experience significant recovery of swallowing function within the first few weeks (subacute phase, typically lasting up to 3 months), estimates suggest that up to 50% of stroke survivors may exhibit signs of persistent dysphagia beyond this period [14].

The management of PSD has garnered considerable attention, with current guidelines offering comprehensive recommendations for acute‐phase care. These include systematic screening, early identification, and intervention protocols that have been shown to improve immediate outcomes [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. However, guidance for managing patients with long‐term dysphagia remains sparse. This is unfortunate, as long‐term dysphagia has profound implications not only for physical health but also for psychosocial well‐being, as persistent dysphagia can significantly impair quality of life and increase caregiver burden [1, 15, 16]. Recent advances, including behavioral rehabilitation strategies, pharmacological approaches, and neurostimulation techniques, have shown potential in enhancing dysphagia recovery [17]. Additionally, there is growing evidence that intensified and targeted treatments can promote recovery even in patients with long‐term dysphagia, suggesting that standardized follow‐up protocols and individualized care strategies could substantially improve outcomes [18, 19].

2. Aims and Hypothesis

This position paper synthesizes current guideline recommendations on PSD management, highlights critical gaps in long‐term care, and underscores the need for standardized, evidence‐based follow‐up strategies. We propose that structured reassessment intervals and individualized rehabilitation approaches could improve long‐term outcomes for stroke survivors with persistent dysphagia.

3. Methods

3.1. Guideline Selection

International guidelines and recommendations on PSD management were identified using a two‐step approach. First, we leveraged the recent systematic review by Gao et al. (2023), which assessed the quality of PSD guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool [20, 21]. This review provided a structured evaluation of guidelines and recommendations issued by national and international medical societies and expert panels, ensuring the inclusion of moderate‐to‐high quality guidelines [21].

To supplement this, a targeted PubMed search was conducted to identify additional guidelines or recommendations—potentially focusing on post‐acute dysphagia care—published between January 2014 and January 2025 that were not included in the Gao et al. review. The search terms used were “stroke,” “dysphagia,” “guidelines,” and “recommendations,” which yielded 79 results. All identified records were screened by one author based on predefined inclusion criteria, requiring guidelines to be issued by national or international medical societies or expert panels, published in peer‐reviewed English‐language journals, and contain specific recommendations for PSD management across the acute, subacute, and chronic phases. Guidelines and recommendations were further assessed for methodological quality, with inclusion restricted to those rated as moderate‐to‐high quality, consistent with the selection criteria established in Gao et al. (2023) [21]. Both identified guidelines were rated as moderate quality and therefore included in the analysis. A flow diagram (Figure 1) provides an overview of the selection process and included guidelines.

FIGURE 1.

FIGURE 1

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Flow chart of guideline identification.

3.2. Data Extraction and Analysis

For the purposes of this study, guidelines and recommendations were defined as systematically developed statements designed to assist healthcare professionals in making evidence‐based decisions about managing PSD. Data were extracted focusing on key recommendations related to screening procedures, diagnostic assessments, management strategies, and reassessment intervals across the acute, subacute, and chronic phases of PSD care. Screening recommendations included details on timing, tools used, and designated healthcare professionals responsible for assessments. Diagnostic criteria were reviewed with a focus on clinical and instrumental evaluation methods, including videofluoroscopy (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES). Reassessment protocols were analyzed to determine the frequency and methodology of follow‐up evaluations, while management strategies were assessed in terms of rehabilitation and therapy approaches for dysphagia across acute, subacute, and chronic post‐stroke phases.

4. Results

Of 16 identified guidelines, 10 were included in the final analysis (Figure 1) [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Recommendations for screening, diagnosis, management, and follow‐up of PSD of included guidelines are given in Table 1. An overview of these recommendations is also presented in Figure 2.

TABLE 1.

Guideline recommendations on acute and post‐acute management of post‐stroke dysphagia.

Screening for post‐stroke dysphagia

  1. A standardized screening should be done early within 24 h or as soon as possible [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]

  2. Patients should be assigned on NPO before screening has been performed [1, 2, 3, 4, 5, 6, 8, 9, 10]

  3. Water‐swallow‐tests or mixed‐consistency tests should be used [1, 2, 9, 10]

  4. Screening should be administered by trained staff [1, 2, 3, 4, 5, 6, 8, 9, 10]

Assessment of post‐stroke dysphagia
  1. Further dysphagia assessment should be done as early as possible in
    1. all patients failing initial dysphagia screening [1, 2, 5, 6, 9]
    2. presenting with factors associated with post‐stroke dysphagia1–5,7,9
      1. Severe facial palsy, aphasia or dysarthria1
      2. Moderate to severe stroke (National Institutes of Health Stroke Scale NIHSS ≥ 10)1
      3. Coughing, choking, wet voice, food‐residuals in the mouth2
      4. Cognitive impairment2
      5. Pneumonia2
      6. Assumed aspiration2,3
  2. Further dysphagia assessment should be done by
    1. Clinical and/or instrumental swallowing examination (VFSS/FEES)1,2,5,6,9
    2. Instrumental swallowing examination (VFSS/FEES)3,4,7
Management of post‐stroke dysphagia

  1. Oral health care interventions should be implemented1,3,4,9,10

  2. Patients should be screened for malnutrition after hospital admission (during 48 h)2,5,6,9

  3. Use of oral nutrition supplements should be considered in patients with malnutrition1–3,5,9

  4. Enteral nutrition should be used in patients with insufficient oral intake within the first week via1–3,5,6,9,10
    1. NGT in patients with expected nutritional support for 3–4 weeks1–3,6,9,10
    2. PEG in patients with expected chronic nutritional support1–3,6,9,10
  5. Texture‐modified diet and thickened liquids should be used based on appropriate swallowing diagnostics1,2,6,9,10
    1. Patients should be monitored in fluid & nutritional intake1,2,9
    2. Carbonated liquids may be used for patients with pharyngeal residue2
  6. Dysphagia therapy should be started early and include
    • a
      Behavioral maneuvers and exercises1–3,5,7–10
    • b
      Pharmacological treatment
      1. Not generally recommended or only within clinical trial setting1,9
      2. TRPV1‐agonists or dopaminergic agents1,2
      3. Metoclopramide in patients with NGT (to prevent esophago‐pharyngeal regurgitation)1
    • c
      Neurostimulation techniques (including rTMS, TES, tDCS & PES)1,8,10
      1. Recommended primarly within a clinical trial setting1,2,9
      2. Should be considered as add‐on therapy1,2,10
      3. PES, especially in tracheotomized patients1,7
    • a
      Acupuncture procedures1,3,9

  7. Use of preventive antibiotics is not recommended1

  8. Patients, care givers and family members should be instructed and informed6,10

Follow‐up of post‐stroke dysphagia

  1. The ability to swallow pills and liquid/different food consistencies should be routinely evaluated1,2,9

  2. Follow‐up intervals should be daily during the acute phase and weekly until stability is reached11

  3. Patients should be re‐assessed before discharge or transfer to rehabiliation6

  4. In post‐acute phase and after hospital discharge, follow‐up intervals should be11
    1. Monthly in the 3‐ to 6‐month phase
    2. Every other month in the 6‐ to 12‐month phase
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Note: 1ESO/ESSD 2021, 2ESPEN 2018, 3AHA/ASA 2016, 4AHA/ASA 2019, 5CSA 2019, 6CSA 2022, 7Brazil 2022, 8Japan 2024, 9Portugal 2022, 10,11Turkey 2021/2022.

Abbreviations: FEES = fiberoptic endoscopic evaluation of swallowing, NGT = nasogastric tube, NIHSS = national Institutes of Health Stroke Scale, NPO = nil per os, PEG = percutaneous endoscopic gastrostomy, PES = pharyngeal electrical stimulation, rTMS = repetitive transcranial magnetic stimulation, tDCS = transcranial direct current stimulation, TES = transcutaneous electrical stimulation, TRPV1 = transient receptor potential vanilloid 1, VFSS = videofluoroscopic swallow study.

FIGURE 2.

FIGURE 2

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Overview of key recommendations for post‐stroke dysphagia. FEES = fiberoptic endoscopic evaluation of swallowing, ONS = oral nutrition supplements, PES = pharyngeal electrical stimulation, VFSS = videofluoroscopic swallow study.

4.1. Screening for Post‐Stroke Dysphagia

All guidelines emphasize the importance of early screening for PSD, recommending that it should be conducted as soon as possible, but especially within the first 24 h of admission [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. Nine of 10 (90%) guidelines advise keeping patients nil per os (NPO) until formal screening is completed [1, 2, 3, 4, 5, 6, 8, 9, 10]. The same 9 (90%) guidelines recommend that screening should be performed by trained staff, including nurses, speech and language pathologists, or physicians, depending on regional practices [1, 2, 3, 4, 5, 6, 8, 9, 10]. Four of 10 (40%) guidelines, which were exclusively from European countries, explicitly recommend standardized tools such as the water‐swallow test or mixed‐consistency test for initial dysphagia screening [1, 2, 9, 10].

4.2. Assessment of Post‐Stroke Dysphagia

For patients who fail initial screening or present with predictive factors for PSD, 8 of 10 (80%) guidelines recommend further assessment [1, 2, 3, 4, 5, 6, 7, 9]. The identification and definition of predictive factors for PSD vary among the guidelines, as detailed in Table 1. European and Canadian guidelines suggest clinical swallowing examinations performed by speech therapists, whereas American guidelines recommend direct referral to instrumental procedures, such as videofluoroscopic swallow studies (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) [1, 2, 3, 4, 5, 6, 7, 9]. Regional variations in clinical practice influence diagnostic recommendations, with some guidelines emphasizing physician‐led assessments, while others prioritize speech‐language pathologists. For instance, Turkish guidelines address the involvement of physicians in diagnostics, highlighting regional variations in professional roles [10].

4.3. Management of Post‐Stroke Dysphagia

Guidelines consistently recommend multifaceted management strategies, integrating dietary, nutritional, and behavioral interventions. Most emphasize early dysphagia interventions, including compensatory maneuvers (8 of 10%–80%), enteral nutrition in high‐risk patients (7 of 10%–70%), and therapeutic swallowing exercises (8 of 10%–80%) [1, 2, 3, 5, 6, 7, 8, 9, 10, 11]. Oral health care interventions are advised to prevent aspiration pneumonia (5 of 10%–50%), nutritional screening within 48 h of admission (4 of 10%–40%) and dietary modifications (5 of 10%–50%) are recommended [1, 2, 3, 4, 5, 6, 9, 10, 11].

Oral nutrition supplements should be considered in patients with evident malnutrition [1, 2, 3, 5, 9]. Enteral nutrition is suggested for patients with severe dysphagia and insufficient oral intake, with nasogastric tubes (NGT) recommended for short‐term support (3–4 weeks) and percutaneous endoscopic gastrostomy (PEG) considered for those requiring prolonged nutritional assistance [1, 2, 3, 4, 5, 6, 9, 10, 11]. Texture‐modified diets and thickened liquids are advised based on individualized swallowing diagnostics, with carbonated liquids mentioned in one guideline for patients with pharyngeal residue [1, 2, 5, 6, 9, 11].

Recommendations on restitutive strategies vary across guidelines. Behavioral therapies and exercise‐based interventions are widely recommended (8 of 10%–80%). Selected guidelines recommend pharyngeal electrical stimulation in patients with tracheostoma (2 of 10%–20%), whereas other pharmacological and neurostimulation techniques are primarily advised within a clinical trial setting [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Three of 10 (30%) guidelines recommend the use of acupuncture procedures based on the available evidence in the literature [1, 3, 7, 9]. Two guidelines also highlight the importance of educating patients, caregivers, and healthcare teams to ensure adherence to dysphagia management strategies (2 of 10%–20%) [6, 10, 11].

4.4. Follow‐Up of Post‐Stroke Dysphagia

Recommendations for follow‐up care are sparse and lack detailed guidance. Only 3 of 10 (30%) guidelines provide general suggestions to evaluate swallowing function regularly, including the ability to swallow pills, liquids, and foods of different consistencies, but do not specify methods or tools that should be applied [1, 2, 9]. Canadian Stroke Best Practice Recommendations include reassessing patients before hospital discharge or transfer to another institution [6]. The Turkey Delphi Recommendations stand out as they include specific follow‐up intervals. These intervals suggest daily assessments in the acute phase until clinical stability is achieved, weekly evaluations until hospital discharge, monthly follow‐ups during 3 to 6 months post‐stroke, and follow‐ups every other month during the chronic phase (6 to 12 months post‐stroke) [10, 11].

5. Discussion

PSD is a well‐recognized clinical challenge, with strong international consensus on the importance of early identification and management. Most guidelines emphasize dysphagia screening within the first 24 h of hospital admission, ensuring timely intervention to mitigate complications such as aspiration pneumonia and malnutrition [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Additionally, there is broad agreement that patients should receive early therapeutic interventions including compensational and restitutive strategies to ensure successful rehabilitation [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Despite these advancements in acute‐phase care, long‐term management strategies remain poorly defined and inconsistently addressed across guidelines.

5.1. Level of Evidence Across Recommendations and Gaps in Long‐Term Dysphagia Care

While acute‐phase dysphagia management is well‐defined, structured recommendations for long‐term follow‐up remain limited [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. The absence of standardized reassessment intervals and chronic‐phase rehabilitation strategies reflects the lack of high‐quality evidence supporting long‐term management approaches. The strength of supporting evidence varies substantially across PSD management domains. Recommendations for early screening and diagnosis, and initiation of early dysphagia therapy—including behavioral and compensatory exercises as well as enteral nutrition—are supported by moderate to high levels of evidence, as reflected in multiple guidelines [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. In contrast, several common practices—such as screening for malnutrition, applying texture‐modified diets, routine re‐evaluation of swallowing function, and structured long‐term follow‐up intervals—are based on expert consensus or limited evidence [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. These areas present key priorities for future research to establish high‐quality, evidence‐based standards of care.

Only a few guidelines provide guidance on when and how to reassess swallowing function beyond the acute phase, leaving clinicians to rely on local practice patterns. One notable exception is the Turkish Delphi recommendations, which recommend structured follow‐up extending into the chronic phase [11]. However, its reliance on expert consensus rather than systematic evidence underscores a critical gap: the absence of robust, prospective studies guiding long‐term PSD management.

Emerging research exists supporting the positive effect of interventions on post‐acute PSD management [22, 23, 24]. Intensified and targeted reassessments—integrated into post‐stroke care—resulting in further referrals to rehabilitative interventions have been shown to promote recovery even in patients with long‐term dysphagia [18]. Furthermore, high‐intensity dysphagia therapy led not only to improved dysphagia recovery rates, but also to a trend toward more favorable outcomes including independency, lower rates of chest infections, and overall survival [19]. Conversely, treatments that are beneficial in the acute phase, such as dietary modifications aimed at preventing or reducing aspiration, may have diminished benefits or even pose increased risks when extended into long‐term use [17]. These examples highlight the need for stratified, evidence‐based long‐term management strategies that balance rehabilitation potential with patient safety and potential adverse (long‐term) effects.

5.2. Research Priorities and Future Directions

To bridge these gaps, future research must prioritize structured long‐term follow‐up protocols, focusing on key unanswered questions: What is the optimal frequency and modality of dysphagia reassessment? Which rehabilitation approaches are most effective for sustained recovery, and how do their effects and potential side effects vary between acute and post‐acute settings? Which patient subgroups derive the greatest benefit from extended rehabilitation? How do emerging interventions—such as neurostimulation or pharmacological therapies—translate into meaningful, long‐term clinical improvements? The lack of large‐scale, prospective trials in these areas limits the ability to formulate standardized recommendations.

A structured, multidisciplinary approach—integrating stroke physicians, nurses, speech‐language pathologists, nutrition, and rehabilitation specialists—could enhance long‐term outcomes by ensuring ongoing reassessment and individualized rehabilitation. Future clinical trials should explore the comparative effectiveness of different rehabilitation strategies and validate structured follow‐up protocols. By addressing these research priorities, the field can move toward a more comprehensive and standardized approach to PSD management beyond the acute phase.

6. Conclusion

Significant progress has been made in the early recognition and management of PSD, yet the absence of structured long‐term follow‐up represents a major gap in stroke care. The lack of clear guidelines for chronic‐phase dysphagia management reflects a deficiency in available research rather than inconsistencies in clinical guidance. Closing this gap requires well‐designed studies to define optimal reassessment intervals, rehabilitation strategies, and patient‐centered outcomes. Future guidelines must evolve to include standardized, evidence‐based recommendations for long‐term PSD management, ensuring improved care for stroke survivors with persistent dysphagia.

Author Contributions

Anel Karisik: conceptualization, methodology, investigation, writing – original draft, writing – review and editing, visualization, validation, formal analysis, data curation, project administration. Bendix Labeit: methodology, validation, visualization, writing – review and editing, writing – original draft, investigation, formal analysis, project administration, supervision. Alois Josef Schiefecker: writing – review and editing, validation, formal analysis, supervision. Simon Sollereder: validation, writing – review and editing, formal analysis, supervision. Oliver Galvan: validation, writing – review and editing, formal analysis, supervision. Simone Graf: validation, writing – review and editing, formal analysis, supervision. Stefan Kiechl: validation, writing – review and editing, formal analysis, supervision, project administration. Michael Knoflach: project administration, formal analysis, supervision, writing – review and editing, validation. Lukas Mayer‐Suess: writing – review and editing, writing – original draft, conceptualization, investigation, methodology, validation, visualization, formal analysis, project administration, data curation, supervision.

Conflicts of Interest

None of the other authors report disclosures relevant to this research. B.L. and A.J.S. have received honoraria from Phagenesis not related to this work.

Acknowledgements

Open access funding provided by Medizinische Universitat Innsbruck/KEMÖ.

Anel Karisik and Bendix Labeit share first authorship.

Funding: The authors received no specific funding for this work.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

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This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Articles from European Journal of Neurology are provided here courtesy of John Wiley & Sons Ltd on behalf of European Academy of Neurology (EAN)

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