Dysphagia (Swallowing Difficulty)

Dysphagia is difficulty swallowing: food, drink or saliva does not move safely and easily from the mouth to the stomach.⁠^1,2 It affects about 1 in 25 US adults a year, and stroke is the most commonly reported cause.⁠^1,3 A speech-language pathologist tests swallowing and treats it with exercises, safer ways of eating and changes to food and drink (see speech therapy for adults).⁠^1,4

What is dysphagia?

Dysphagia is a swallowing disorder involving the mouth, the throat (pharynx), the esophagus or the junction of the esophagus and stomach.⁠¹ Everyone has trouble swallowing now and then, after eating too fast or not chewing well; with dysphagia, the trouble is ongoing, and it can affect liquids, food and even saliva.⁠^2,4 Much of swallowing happens without your being aware of it once it starts.⁠¹³

Swallowing happens in three phases: in the mouth, chewing and moving food or liquid back to the throat; in the throat, starting the swallow, squeezing food down and closing off the airway; and in the esophagus, the tube that carries food to the stomach.⁠⁴ Clinicians also name an oral preparatory phase before the first, and look at each phase in a swallow study.⁠⁶

Dysphagia matters because of what it leads to: malnutrition and dehydration, aspiration pneumonia, poorer general health, chronic lung disease, choking and even death.⁠¹ It also takes the pleasure out of meals; people may feel embarrassed, lose interest in eating, or want to eat alone.⁠^1,4 Speech-language pathologists (SLPs) are the preferred providers for swallowing problems in the mouth and throat; speech therapy explains what they do.⁠¹

How common is dysphagia?

Each year about 1 in 25 US adults has a swallowing problem: an estimated 9.44 million people, or 4.0%, in the 2012 National Health Interview Survey, of whom only 22.7% saw a health professional for it.⁠^1,3 Because it cuts across so many diseases, its true prevalence is not fully known and is often underestimated.⁠¹ How common it is in different groups, as each source gives it:

What is aspiration?

Aspiration is food, drink or saliva entering the airway and lungs instead of the esophagus; it is a common problem for people with dysphagia.⁠^4,5 Penetration is when material enters the airway but stays above the vocal folds; on the 8-point Penetration-Aspiration Scale clinicians use, 1 means nothing entered the airway and 8 means material passed below the vocal folds with no effort to clear it.⁠^6,17 Aspiration is what links dysphagia to pneumonia: in a review of stroke studies, dysphagia roughly tripled the risk of pneumonia (relative risk 3.17), and aspiration raised it about elevenfold (11.56).⁠¹⁵ ASHA cites an estimate that about a third of people with dysphagia develop pneumonia and that 60,000 people die each year from such complications.⁠¹

What causes dysphagia?

Anything that affects the nerves, muscles or structures of swallowing can cause dysphagia.⁠^1,13 The causes ASHA, MedlinePlus and the CHSA list:

• Brain and nerve conditions: stroke, traumatic brain injury, spinal cord injury, dementia, Parkinson’s disease, multiple sclerosis, ALS, myasthenia gravis, muscular dystrophy and post-polio syndrome.⁠^1,13 Stroke was the most commonly reported cause in the national survey.⁠³
• Head and neck cancer and its treatment: cancer of the mouth, throat or esophagus, surgery to the mouth, jaw or throat, and radiation or chemoradiation.⁠^1,18
• Injury or surgery involving the head and neck, and decayed or missing teeth.⁠¹
• A stay in intensive care, especially with a breathing tube or a tracheostomy, and recovery from a critical illness.⁠¹
• Medicines, some of which cause dry mouth, which makes it hard to chew and swallow.⁠^1,4,19
• Other illnesses: infections such as COVID-19 and sepsis, lung disease such as COPD, heart and chest surgery, and frailty.⁠¹
• Esophageal causes: a narrowing (stricture) from reflux, radiation, medicines or ulcers; achalasia, in which the muscle at the bottom of the esophagus fails to relax; eosinophilic esophagitis, an allergic condition; esophageal spasms, rings and cancer; and gastroesophageal reflux disease (GERD), linked to dysphagia in about 14% of people with it.⁠^1,13

Is trouble swallowing a normal part of aging?

Not in itself. Swallowing slows subtly with age, which clinicians call presbyphagia, but age-related disease, not healthy aging, is the main cause of swallowing problems that matter in older adults.⁠^14,16 Dry mouth is not a normal part of aging either.⁠¹⁹ Older people are often unaware of their own swallowing problem, so malnutrition, dehydration and pneumonia can be the first clues.⁠¹⁶

What are the types of dysphagia?

Dysphagia is grouped by where the problem is:

What is hard to swallow gives clues: trouble with solids only suggests a physical blockage such as a stricture or a tumor, while trouble with liquids but not solids may point to nerve damage or a spasm of the esophagus.⁠¹³ A lump feeling in the throat that is unrelated to eating is called globus, and is different from dysphagia.⁠¹³

What is silent aspiration?

Silent aspiration is food or drink entering the airway without any outward sign: no cough, no choking.⁠^1,17 Normally aspiration causes a violent cough, but a stroke can reduce sensation, so a person may not know they are aspirating.⁠⁵ It is common after radiation for head and neck cancer, with reports of up to 35% of patients.⁠¹⁷ Only an instrumental test, such as a modified barium swallow study or FEES, can confirm it.⁠¹

What are the signs and symptoms of dysphagia?

The signs ASHA, the CHSA and MedlinePlus list:

• Coughing, choking or throat clearing during or after eating or drinking.⁠^1,20
• A wet or gurgly voice, or gurgling sounds from the throat, during or after a meal.⁠^4,20
• Food that sticks: a feeling that something is stuck in the throat or chest after eating or drinking.⁠⁴
• In the mouth: drooling, food or liquid leaking from the lips, food left in the mouth after the swallow, and extra time needed to chew or swallow.⁠¹
• Through the nose: food or liquid coming out of the nose.⁠¹
• Pain when swallowing, and trouble coordinating breathing and swallowing, or a hard time breathing after meals.⁠^1,5
• Coughing food back up after eating.⁠²⁰
• Changes in eating: avoiding certain foods or drinks, and weight loss, malnutrition or dehydration from not eating enough.⁠^1,20
• Chest infections: repeated aspiration pneumonia, respiratory infections or fever.⁠¹

No single sign settles it. Coughing during meals may come from reflux, an esophageal problem or a medicine rather than aspiration, and the absence of a cough does not rule aspiration out, so clinicians weigh the whole picture.⁠¹ After treatment for head and neck cancer, needing to swallow many times to clear food, dry mouth and difficulty opening the mouth wide are common signs.⁠²¹

When is a swallowing problem an emergency?

Choking. A person who is choking may be unable to speak, have difficulty breathing, or cough only weakly. If they are coughing forcefully and can speak, do not intervene; if not, have someone call 9-1-1 while you act: give repeated cycles of 5 back blows followed by 5 abdominal thrusts until the object comes out or the person becomes unconscious, using chest thrusts instead for a pregnant or obese person, and begin CPR if the person loses consciousness.⁠¹⁰ Without oxygen, brain damage can begin in as little as 4 minutes, and anyone who has choked should have a medical exam afterward.⁠¹⁰

Food stuck in the airway with trouble breathing: call 9-1-1 right away.⁠²

Contact a provider right away if you feel as if you are choking during or after eating or drinking, or you cough or vomit up blood.⁠¹³ Signs of aspiration pneumonia include coughing up foul-smelling, greenish or dark phlegm and bluish lips; chest pain, chills, fever, shortness of breath or wheezing are reasons to contact a provider, go to the emergency room or call 9-1-1.⁠²²

Swallowing trouble that starts suddenly with stroke signs needs emergency care:

How is dysphagia diagnosed?

A health care provider orders the tests and may refer you to a speech-language pathologist, or to a doctor who specializes in the ear, nose and throat (otolaryngologist), the digestive system (gastroenterologist) or the nervous system (neurologist).⁠^2,13 It helps to bring a list of your swallowing problems, and some tests need you to fast for several hours or more.⁠² The steps usually run from a screen to a full evaluation to an instrumental study.⁠¹

What is a swallow screen?

A screen is a check for signs of aspiration, often by watching how easily a person drinks water from a cup; one example ASHA names is the 3-ounce water swallow test.⁠^1,2,24 An SLP or another member of the care team, such as a nurse the SLP has trained, can do it.⁠^1,24 A screen only shows who is at risk; no bedside screen predicts aspiration well enough on its own.⁠^1,2

After a stroke, the 2026 AHA/ASA guideline for acute ischemic stroke, which replaced the 2018 guideline and its 2019 update:⁠²⁵

• Recommends a bedside swallow screen before any food or drink, to find people at higher risk of aspiration (class 1).⁠²⁶
• Finds it reasonable for the screen to be done by speech pathologists or other trained health care professionals (class 2a).⁠²⁶
• Finds it reasonable to do an instrumental assessment, such as FEES, for people who fail the screen or cannot take part in it (class 2a).⁠²⁶

The 2026 rehabilitation guideline’s summary for SLPs adds that SLPs should screen within 24 hours of admission and before anything is taken by mouth, and that suspected dysphagia should get an instrumental study rather than a bedside evaluation alone.⁠²⁷ While waiting, people are often kept on precautions or nothing by mouth, which can also delay medicines taken by mouth.⁠^5,24

What happens in a clinical swallow evaluation?

The SLP examines the mouth and the nerves and muscles of swallowing, then watches you swallow different foods and drinks, such as water, other liquids, soft foods and solids, checking the teeth, lips, jaw, cheeks and neck as you swallow.⁠^1,2 This bedside or clinic evaluation cannot show what happens inside the throat: only instrumental procedures show the anatomy and the physiology of the swallow.⁠¹

What is a modified barium swallow study?

The videofluoroscopic swallowing study (VFSS), also called the modified barium swallow study, is an X-ray video of swallowing, usually done in a hospital by an SLP and a radiologist.⁠⁶ You sit or stand and swallow different foods and liquids mixed with barium, which shows up on the X-ray, so the SLP can watch where each mouthful goes through the mouth, throat and upper esophagus.⁠^2,4,6 The SLP can try postures and strategies during the study to see which ones work, and uses it to choose exercises, the safest diet and whether other nutrition is needed.⁠⁶

The radiation dose is very low and not considered harmful for most people, but the test is not done in pregnancy, and stools may look white for several days after it.⁠² Its limits: a short, timed sample that may not reflect a real meal, barium that some people refuse, and an allergy to contrast that rules it out; the SLP assesses swallowing, while the physician makes medical diagnoses such as reflux or a tumor.⁠⁶

What is a FEES swallow test?

In a flexible endoscopic evaluation of swallowing (FEES), a thin, flexible tube with a light and camera is passed through the nose to the back of the throat while you eat and drink small amounts, sometimes colored with dye.⁠^2,7 It can be done by an SLP, a physician or both, at the bedside or in a clinic, with no radiation, and a numbing medicine may be used; it can be uncomfortable as the scope goes in, but serious complications are rare.⁠^2,7 FEES cannot see the mouth or the esophagus, and the moment of the swallow itself is hidden by reflected light.⁠⁷

What other swallowing tests might a doctor order?

For problems in the esophagus, doctors use other tests, which ASHA lists among procedures done by other specialists.⁠¹ A barium swallow (esophagram) is an X-ray of the throat and esophagus guided by a radiologist and a technologist; the barium is thick and chalky, and stools may be gray or white for 48 to 72 hours.⁠²⁸ An upper endoscopy passes a flexible tube through the mouth to the stomach under sedation, and can widen a narrowed esophagus; esophageal manometry measures the pressures in the esophagus.⁠^1,13

What is swallowing therapy, and does it work?

Swallowing therapy aims to make swallowing safer and more efficient, keep a person well fed and hydrated, and return them to eating by mouth.⁠¹ It works in two ways. Compensatory techniques, such as postures, smaller mouthfuls and changed textures, alter the swallow while they are used but do not create lasting change; rehabilitative techniques, such as exercises, aim to change the swallow over time by improving the underlying function.⁠¹ The SLP chooses options case by case after the assessment.⁠¹

What swallowing strategies and postures help?

• Chin tuck (chin down toward the neck during the swallow): may reduce penetration and aspiration in some people, but the more severe the dysphagia, the less it helps.⁠¹
• Head turn toward the weak or damaged side, or head tilt toward the strong side to keep food on the chewing surface.⁠¹
• Mouthful size and pace: bigger mouthfuls for people who need more to trigger a swallow, smaller ones for people who need several swallows each, and reminders to keep a safe pace.⁠¹
• Effortful swallow: swallowing hard while pushing the tongue against the roof of the mouth.⁠¹
• Mendelsohn maneuver: holding the voice box up at the peak of the swallow.⁠¹
• Supraglottic swallow: holding the breath just before swallowing, then coughing right after.⁠¹

Some maneuvers need multistep directions, so they may not suit people with cognitive problems.⁠¹ People who can follow them can learn from biofeedback, watching their own swallow on the test images, and the 2026 stroke rehabilitation guidance names biofeedback and pharyngeal electrical stimulation as add-ons to behavioral therapy for selected patients.⁠^1,27

What swallowing exercises work?

Several exercises have been tested in trials, mostly small ones. The programs as the trials ran them:

The UK’s 2023 stroke guideline asks for behavioral exercises such as chin tuck against resistance at least 5 days a week.⁠³³ One author of the expiratory muscle training trial reported a potential royalty interest in the company that makes the device.⁠³¹

Does swallowing therapy help after a stroke?

Probably, though the evidence is weaker than it should be. The 2026 Cochrane review, 181 trials with 11,500 people treated within six months of a stroke, found:⁠⁸

• Behavioral therapy may reduce swallowing impairment and the number still dysphagic at the end of treatment (very low-certainty evidence), and may reduce penetration-aspiration scores and chest infections (low certainty).⁠⁸
• Neuromuscular electrical stimulation probably reduces swallowing impairment (moderate certainty).⁠⁸
• Pharyngeal electrical stimulation may have little to no effect on swallowing impairment, but may reduce penetration-aspiration scores and chest infections (low certainty), and probably helps people come off a tracheostomy tube (moderate certainty).⁠⁸
• Brain stimulation: tDCS probably, and TMS may, reduce swallowing impairment; acupuncture’s effect is uncertain.⁠⁸

The review warns that small trials at risk of bias limit these conclusions.⁠⁸ The 2026 acute stroke guideline rates pharyngeal electrical stimulation class 2b (may be reasonable), or 2a for helping people come off a tracheostomy after a ventilator, and the rehabilitation guideline’s SLP summary says behavioral swallowing treatments are effective for swallowing, food tolerance and quality of life.⁠^26,27 ASHA’s older review called the benefits of electrical stimulation unclear.⁠¹

More therapy also helped in one large trial: of 306 people with dysphagia after an acute stroke, those given swallowing therapy had fewer swallowing-related complications and chest infections than usual care, and high-intensity therapy, at least daily for up to a month, returned more people to a normal diet and to normal swallowing by 6 months.⁠³⁴

What are IDDSI levels, and do thickened liquids help?

Changing the texture of food and the thickness of drinks is one of the most common dysphagia treatments, and SLPs describe it with the IDDSI framework, an international initiative founded in 2013 to give texture-modified foods and thickened drinks shared names worldwide.⁠^1,35 It has 8 levels, 0 to 7: drinks are measured on levels 0 to 4 and foods on levels 3 to 7.⁠³⁶

The clinician chooses the level for each person from a full assessment, and the names matter: mix-ups in diet texture have been linked to choking and death.⁠³⁶ The current framework descriptors are version 2.2 (April 2026), used with the 2019 testing methods.⁠^35,37

Do thickened liquids prevent aspiration?

Not reliably. Texture-modified food and thickened drinks may not remove the risk of aspiration and pneumonia, thicker drinks may even be more likely to be aspirated silently, and they raise the risk of dehydration; many people also do not stick with them.⁠^1,14 Few high-quality studies support them.⁠¹⁶ The two largest trials, in people with dementia or Parkinson’s disease who aspirated thin liquids:

• On the X-ray, at that moment (711 people, each trying all three): honey-thick liquid stopped aspiration most often, then nectar-thick liquid, then the chin-down posture; 49% aspirated with all three and 25% with none, and people preferred the chin-down posture.⁠³⁸
• Over 3 months (515 people): pneumonia was similar with thickened liquids and with the chin-down posture (0.116 against 0.098), and dehydration was more common with thickened liquids (6% against 2%); the trial had no untreated group.⁠⁹

Can people with dysphagia drink water?

Only as the SLP advises: thin liquids may need to be thickened.⁠²⁰ Some programs let carefully selected people drink plain water between meals. A review of the Frazier Free Water Protocol, 8 studies with 245 patients, mostly in rehabilitation, found low-quality evidence that it did not increase lung complications and may increase fluid intake, when it is followed closely and people are screened for thinking and mobility.⁠³⁹ ASHA notes that such alternatives can support health when the mouth is kept very clean.⁠¹

How can you eat safely with dysphagia at home?

Follow the SLP’s plan first; these are the general steps MedlinePlus, the American Stroke Association and others give:

• Sit up as straight as possible to eat and drink, and never eat or be fed lying down or drowsy.⁠^5,20,40
• Small bites, less than a teaspoon (5 mL), and small sips; chew well and swallow before the next bite, using the stronger side of the mouth if one side is weak.⁠^5,20
• One texture at a time: do not mix solids and liquids in the same bite, or wash food down with a drink, unless your therapist says it is OK.⁠²⁰
• Calm, focused meals, without distractions, and no talking while swallowing.⁠^5,20
• Stay upright afterward: MedlinePlus says for 30 to 45 minutes after eating.⁠²⁰
• Thin liquids only if allowed: check with your provider or therapist first.⁠²⁰
• Dentures that fit, food cut into small pieces, and not too much alcohol before or during meals.⁠¹⁰
• Dry mouth: sipping water or a sugarless drink during meals makes chewing and swallowing easier, if thin liquids are allowed.⁠^19,20

Straws are a matter for your SLP: the National Institute on Aging advises against them in late-stage Alzheimer’s disease, while the American Cancer Society suggests them for people with cancer.⁠^18,40 Medicines need a plan too: some do not come as liquids, crushing others can change how they work, and NICE asks prescribers to review a medicine, or change its form or route, when a person cannot swallow tablets; ask the pharmacist before crushing anything.⁠^1,33 If swallowing problems persist or come back, see a provider.⁠²⁰

Does mouth care prevent pneumonia?

It is sensible and low-risk, but its effect on pneumonia is not proven. NICE asks for mouth care after a stroke, brushing teeth and gums at least twice a day, and the 2026 AHA/ASA guideline says an oral hygiene protocol may be reasonable (class 2b).⁠^26,33 The Cochrane reviews are cautious: after a stroke, 15 trials gave only low-quality evidence, with one gel trial reducing pneumonia; in nursing homes, 6 trials with 6,244 people could not show that professional oral care prevents pneumonia, though it may reduce deaths from pneumonia.⁠^41,42

How can families and caregivers help with dysphagia?

Families can ask the SLP questions, follow the plan, help with the exercises, get food and drinks that can be swallowed safely, and keep track of how much the person eats and drinks.⁠⁴ At meals, a reminder to finish swallowing helps, as does not talking to the person while they eat.⁠^20,40 The SLP should explain any texture changes to whoever prepares the food, and NICE asks teams to tell families how to help someone who coughs or chokes while eating.⁠^1,33

How do you test thickened drinks and foods at home?

IDDSI’s tests are designed for caregivers as well as clinicians, with simple tools: a syringe, forks and spoons.⁠^35,37

• Drinks: fill a 10 mL slip-tip syringe, let it flow for 10 seconds and see how much is left; the amount sets the level. A syringe of another size, including a 12 mL one, gives results that cannot be used.⁠³⁷
• Thickeners: follow the maker’s instructions, mix thoroughly with no lumps or bubbles, test at serving temperature, and test twice or more.⁠^18,37
• Lumps: if the flow suddenly stops, check for lumps; the drink may not be safe.⁠³⁷
• Foods: the fork drip, spoon tilt, fork or spoon pressure, chopstick and finger tests check purees and soft foods.⁠³⁷

Watch for warning signs between visits: coughing, fever or shortness of breath, phlegm that is foul-smelling, green or dark, and unexplained weight loss.⁠^20,22 IDDSI’s past sponsors include the Nestlé Nutrition Institute and Hormel Thick & Easy; IDDSI says its sponsors had no part in designing the framework.⁠^35,37

When is a feeding tube needed for dysphagia?

When swallowing is not safe or a person cannot eat and drink enough, a feeding tube may be suggested; the decision is made with the medical team.⁠^1,5,21 A tube through the nose (nasogastric) is usually the choice for the short term, about 2 weeks, and a tube into the stomach (a gastrostomy, such as a PEG) for the long term; a stomach tube does not always rule out eating by mouth.⁠^1,43

After a stroke, the 2026 AHA/ASA guideline recommends starting enteral feeding within 7 days of admission (class 1) and screening nutrition, preferably within 48 hours, and finds it reasonable to start with a nasogastric tube and to place a gastrostomy when swallowing is expected to stay unsafe for more than 2 to 3 weeks (class 2a).⁠⁴⁴ In the FOOD trials, early tube feeding cut the risk of death by 5.8 percentage points, a result that could be chance, at the cost of more survivors with a poor outcome; a PEG instead of a nasogastric tube raised the risk of death or poor outcome by 7.8 points, and the authors concluded their data did not support early PEG feeding.⁠⁴⁵

Three things to know:

• A tube does not stop aspiration. People fed by tube remain at risk of aspirating, and a PEG does not prevent aspiration pneumonia in severe dementia.⁠^16,43
• Therapy continues. Tube feeding does not replace rehabilitation toward eating by mouth, small tastes for pleasure may still be possible with precautions, and the tube can be weaned as swallowing improves.⁠^1,43
• The person decides. Tubes are discouraged in advanced dementia, and a person with decision-making capacity, or their decision-maker, may accept or refuse one; NICE asks teams to respect the choice of someone who wishes to eat and drink knowing the risk.⁠^1,33,43

What happens in swallowing therapy, session by session?

Therapy follows the assessment, and the SLP adjusts the plan as you progress, re-testing when your swallowing or health changes.⁠¹ Sessions can be one on one, in a group at mealtime or by telepractice, and the amount of therapy is set for each person.⁠¹ A course of outpatient therapy, as Medicare structures it:

The trial programs give a sense of the time involved: 3 weeks of daily 1-hour sessions (McNeill program), 4 weeks of home training 5 days a week (expiratory muscle training) and 4 weeks of chin tuck against resistance, up to a month of daily therapy after a stroke, and 6 to 8 weeks for the head lift.⁠^{17,29,30,31,32,34} The 2026 rehabilitation guidance says telehealth should be considered to widen access to specialized SLP care, and telepractice should be of equal quality to in-person care.⁠^27,50

Can dysphagia get better?

It depends on the cause. ASHA describes different plans for dysphagia from a sudden event such as a stroke, from a stable condition, and from a progressive disease, where the aim is to make the most of current function and plan ahead.⁠¹

• After a first stroke: in 128 people followed for 6 months, 87% of survivors were back on their pre-stroke diet, but half still showed a swallowing abnormality, and 20% had a chest infection in that time.⁠⁵¹
• With more therapy: high-intensity therapy after a stroke returned more people to a normal diet and normal swallowing by 6 months.⁠³⁴
• In Parkinson’s disease: severe dysphagia arrives on average 130 months after the first symptoms, but more than half of people who notice nothing already show changes on instrumental tests.⁠¹⁶
• In dementia: dysphagia progresses with cognitive decline, and in late Alzheimer’s disease chewing and swallowing become hard, raising the risk of choking.⁠^16,40
• Esophageal narrowing can often be widened during an upper endoscopy.⁠¹³

How does head and neck cancer affect swallowing?

About half of people with head and neck cancer have dysphagia of the mouth and throat, and more after chemoradiation.⁠¹ Surgery can make it hard to control food and drink in the mouth, and after a laryngectomy, removal of the voice box, starting a swallow and pushing food down can be harder.⁠²¹ Radiation can damage the salivary glands and cause dry mouth, and silent aspiration is common after it.⁠^17,19

You may see an SLP before surgery or radiation, to talk about the changes to expect and start swallowing exercises.⁠²¹ Problems can also appear late: in a case series of 29 survivors seen a median of 9 years after radiation, 86% developed pneumonia, swallowing strategies helped 69% but no one improved lastingly, and 66% ended up dependent on a feeding tube; the authors note that severe late dysphagia seems uncommon.⁠⁵²

Does Medicare cover swallowing therapy?

Yes. Medicare Part B covers outpatient speech-language pathology, including swallowing skills and therapy to maintain function or slow decline, with no yearly limit on what it pays, once a provider certifies you need it.⁠¹¹ Medicare covers dysphagia treatment whether or not there is a communication problem, for people who are motivated, moderately alert and have some swallowing function.⁠¹² Improvement is not required. Medicare covers skilled therapy to maintain function or to prevent or slow decline, not only to restore it, provided the other coverage rules are met; coverage turns on the need for skilled care, not on the potential to improve.⁠⁴⁹

Medicare has no cap on outpatient therapy, but once physical therapy and speech-language pathology together pass $2,480 in a year (the 2026 amount), each claim must confirm that the therapy is medically necessary, and claims past $3,000 can be picked for review.⁠⁵⁷

Medicaid, Marketplace plans and the VA. For adults, speech, hearing and language services are an optional Medicaid benefit, so coverage depends on your state; home health is a mandatory benefit.⁠⁵⁸ Every Marketplace plan covers rehabilitative and habilitative services and devices, though the specific services vary with each state’s requirements.⁠⁵⁹ For veterans, audiology and speech pathology are standard medical benefits for every enrolled veteran.⁠⁶⁰ With any private plan, ask about visit limits, whether a referral is needed, and whether the SLP is in network.

Which conditions are linked to dysphagia?

• Aspiration pneumonia: a lung infection from food, liquid or saliva breathed into the airways; swallowing problems, poor oral hygiene, frailty and age raise the risk; it is treated with antibiotics, and a swallowing test may be needed.⁠^1,22,43
• Reflux (GERD) and esophageal disorders: qualified SLPs may screen for them and refer for treatment.⁠¹
• Dry mouth, which makes chewing, swallowing and talking hard; hundreds of medicines and radiation to the salivary glands can cause it.⁠¹⁹
• Speech and language problems: after a first stroke, one study of 221 people found dysphagia in 44%, dysarthria (slurred speech) in 42% and aphasia in 30%, with dysphagia and dysarthria together in 28%.⁠⁶¹

Other adult speech, language and communication problems have their own causes and treatment: cognitive-communication disorders, voice disorders, stuttering in adults, and communication in dementia. Feeding and swallowing problems in children are covered in feeding therapy.

What are common myths about dysphagia?

• Myth: no cough means no aspiration. Aspiration can be silent, and no bedside screen reliably predicts it.⁠^1,5
• Myth: thickened liquids prevent pneumonia. They may not remove the risk, and in the largest trial pneumonia was no lower than with a chin-down posture, while dehydration was higher.⁠^1,9
• Myth: a feeding tube stops aspiration. People fed by tube remain at risk.⁠⁴³
• Myth: swallowing trouble is just aging. Disease, not healthy aging, is the main cause in older adults.⁠^14,16
• Myth: with dysphagia you can never drink plain water. Free water protocols let carefully selected people drink water between meals.⁠³⁹

How do you find swallowing therapy near you?

Look for a speech-language pathologist who works with adults who have swallowing problems; SLPs are the preferred providers of dysphagia care, and many have special training in it.⁠^1,4,18 What to know when you choose:

• Training: ASHA certification standards since 2020 require competence in dysphagia, and no special certificate is required to treat it or to do a modified barium swallow study or FEES.⁠^1,6
• Board certification: a Board Certified Specialist in Swallowing and Swallowing Disorders has shown advanced expertise, though specialty certification is voluntary.⁠^1,62
• Instrumental studies: ask where the SLP sends people for a swallow study; some state agencies may require a radiologist to be present for a VFSS, and ASHA does not require a physician for an SLP to perform FEES.⁠^1,7

Every SLP needs a state license. ASHA’s Certificate of Clinical Competence (CCC-SLP) is a national credential whose holders have met standards that typically go beyond state licensure, and anyone can check an SLP’s certification on ASHA’s site.⁠^63,64

The DrSensory speech therapy directory lists practices by state and city. On a city page, set Care for to Adults and Specialty to Feeding / swallowing. A specialty tag comes from the practice’s own description of its services, not from a credential, so ask whether the SLP treats adults with dysphagia and which swallow studies they use when you call.

Telehealth and home visits are options too: Medicare covers telehealth from home through December 31, 2027, and home health for people who are homebound.⁠^53,54 In-home therapy explains how home visits work.

Sources

1. American Speech-Language-Hearing Association. Adult Dysphagia (Practice Portal). “Dysphagia is a swallowing disorder involving the oral cavity, pharynx, esophagus, or gastroesophageal junction”; “Consequences of dysphagia include malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death”. “Each year, approximately one in 25 adults will experience a swallowing problem in the United States”; prevalence runs “up to 68% for residents in long-term care settings”. “Silent aspiration may be present, meaning the patient presents without overt signs or symptoms of dysphagia”; “currently, no bedside screening protocol has been shown to provide adequate predictive value for the presence of aspiration”; “Instrumental procedures are the only method that provides visualization of swallowing physiology and laryngeal, pharyngeal, and upper esophageal anatomy”. “Compensatory techniques alter the swallow when used but do not create lasting functional change”, while exercises are “designed to create lasting change in an individual’s swallowing over time by improving underlying physiological function”; “texture modified foods and thickened fluids may not eliminate the risk of aspiration and associated pneumonia”; for electrical stimulation “the benefits remain unclear”; “Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all populations and may not necessarily improve outcomes or quality of life”. Board certification in swallowing “is a voluntary program and is not required by ASHA to practice in any disorder area”. Checked October 8, 2026.
2. MedlinePlus, National Library of Medicine. Dysphagia Tests (Medical Tests). “But if you have dysphagia, trouble swallowing is an ongoing problem”; “If food has gotten stuck in your airway and you’re having trouble breathing, call 911 for help right away”. In FEES “A provider will slide an endoscope (a thin, flexible tube with a light and camera) into your nose and to the back of your throat”; in a VFSS “You will be given different foods and liquids covered with barium”; “During a FEES or upper endoscopy , you may feel some discomfort when the endoscope is inserted, but serious complications are rare”; for the VFSS “The radiation dose is very low and not considered harmful for most people”. Results can show oral cavity, oropharyngeal (“a disorder of the throat in which you have difficulty starting to swallow”) or esophageal dysphagia; “A bedside swallow screen or other type of dysphagia screening tool will only show if you are at risk for one of the above disorders”. Checked October 8, 2026.
3. Bhattacharyya N. The prevalence of dysphagia among adults in the United States. Otolaryngology–Head and Neck Surgery. 2014;151(5):765–769. doi:10.1177/0194599814549156 (PMID 25193514). From the 2012 National Health Interview Survey: “An estimated 9.44 ± 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% ± 1.6% female) reported a swallowing problem (4.0% ± 0.1%)”; “Overall, 22.7% ± 1.7% saw a health care professional for their swallowing problem”; “Stroke was the most commonly reported etiology (422,000 ± 77,000; 11.2% ± 1.9%)”; “Swallowing problems affect 1 in 25 adults, annually”. Self-reported survey data.
4. Communication Health Support Association (consumer site powered by the American Speech-Language-Hearing Association). Swallowing Disorders in Adults. “A person with a swallowing disorder will have trouble like this a lot of the time”; “Swallowing happens in three stages, or phases” (oral, pharyngeal, esophageal); signs include “having a wet or gurgly voice during or after eating or drinking”; a swallowing problem can cause “food or liquid going into the airway, called aspiration”; in a modified barium swallow “Barium shows up on an X-ray so the SLP can watch where the food goes”; family can help by “Keeping track of how much you eat and drink”. Checked October 8, 2026.
5. American Stroke Association. Trouble Swallowing After Stroke (Dysphagia). Last reviewed April 14, 2024. Untreated, dysphagia “can lead to poor nutrition, pneumonia and disability”; aspiration “occurs when something you’ve swallowed enters the airway and lungs. Normally, aspiration causes a violent cough, but a stroke can reduce sensation. In this case, you may not know you’re aspirating (silent aspiration)”; in the hospital, “you may not be allowed to eat until a speech-language pathologist evaluates how well” the mouth muscles move, you swallow and the voice box works; “If it’s not safe for you to swallow, a feeding tube may be suggested to help meet your nutritional needs”. Precautions: “Sit up straight when you eat or drink”, “Take small bites and sips”, “Avoid distractions to focus on eating”. Checked October 8, 2026.
6. American Speech-Language-Hearing Association. Videofluoroscopic Swallow Study (VFSS) (Practice Portal resource). The VFSS, “also known as the modified barium swallow study , is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function”; “A VFSS is typically conducted in a hospital by a speech-language pathologist (SLP) and radiologist”; “The patient is given various consistencies of food and liquid mixed with barium (or other contrast material), which allows the bolus to be visualized in real time on an X-ray during the swallow”; “The VFSS can also be used to gather information on the influence of compensatory strategies”; “the SLP assesses and documents swallowing physiology and function only, whereas the physician makes medical diagnoses (e.g., reflux, presence of a tumor)”. Limitations include “Time constraints due to radiation exposure” and “A limited sample of swallow function that may not be an accurate representation of typical mealtime function”; “The Penetration–Aspiration Scale (Rosenbek et al., 1996) is an 8-point scale used to describe penetration and aspiration events”. Checked October 8, 2026.
7. American Speech-Language-Hearing Association. Flexible Endoscopic Evaluation of Swallowing (FEES) (Practice Portal resource). FEES “is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally”; “FEES may be conducted by a speech-language pathologist (SLP), a physician, or collaboratively together”; “FEES is used without concerns of radiation exposure and can be used within therapeutic contexts”; the SLP may “provide a topical anesthetic if appropriate”; “aspiration is inferred based on patient response and/or observation of material below the vocal folds after the swallow”. Limitations: “Inability to visualize the oral or the esophageal phase of swallowing” and a “white-out” when the bolus “cannot be observed during the swallow because of reflected light”; “The patient may, on rare occasions, experience adverse effects when undergoing FEES”, including discomfort, vomiting and nosebleed. Checked October 8, 2026.
8. Wilkinson G, Everton LF, Bath PM, Benfield JK. Swallowing therapy for dysphagia in acute and subacute stroke. Cochrane Database of Systematic Reviews. 2026;(8):CD000323. doi:10.1002/14651858.CD000323.pub4 (PMID 42573047). “This review updates the 2018 review”. “We included 181 trials with 11,500 participants (140 new trials (8840 participants) in this update)”. “Behavioural interventions may reduce SI (SMD -1.17, 95% CI -1.60 to -0.74; 26 RCTs, 1224 participants) and DET (OR 0.41, 95% CI 0.30 to 0.57; 9 RCTs, 958 participants)” but with very low-certainty evidence, and they “may reduce PAS (MD -0.99, 95% CI -1.42 to -0.55; 16 RCTs, 586 participants) and CI/P (OR 0.45, 95% 0.27 to 0.76; 8 RCTs, 784 participants) (both low-certainty evidence)”; “NMES probably reduces SI (SMD -0.69, 95% CI -1.01 to -0.37; 20 RCTs, 866 participants; moderate-certainty evidence)”; “PES may have little to no effect on SI”. “Conclusions from our analyses are limited by small trials at high or unclear risk of bias, publication bias and inconsistent results”. (SI: swallowing impairment; DET: dysphagia at end of trial; PAS: penetration–aspiration score; CI/P: chest infection or pneumonia.)
9. Robbins J, Gensler G, Hind J, Logemann JA, Lindblad AS, Brandt D, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Annals of Internal Medicine. 2008;148(7):509-518. doi:10.7326/0003-4819-148-7-200804010-00007 (PMID 18378947). “515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids” were randomized to a chin-down posture or nectar- or honey-thick liquids; 3-month pneumonia incidence was “0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively” (no significant difference); “More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%)”; “A no-treatment control group was not included”; “No definitive conclusions about the superiority of any of the tested interventions can be made”.
10. MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine). Choking – adult or child over 1 year. Review date February 10, 2026. Danger signs: “Inability to speak”, “Difficulty breathing”, “Weak, ineffective coughing”; “Do not perform first aid if the person is coughing forcefully and is able to speak”; “You should perform repeated cycles of 5 back blows followed by 5 abdominal thrusts, until the object comes out or the person becomes unconscious”; “Tell someone to call 911 or the local emergency number”. Checked October 7, 2026.
11. Centers for Medicare & Medicaid Services. Speech-language pathology services (Medicare.gov). Part B covers “medically necessary outpatient speech-language pathology services”, which “provide evaluation and treatment to regain and strengthen speech and language skills. This includes cognitive and swallowing skills, or therapy to improve or maintain current function or slow decline”; “Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify you need this care”; after the Part B deductible you pay 20% of the Medicare-approved amount; “There’s no limit on how much Medicare pays for your medically necessary outpatient speech-language pathology services in one calendar year.” Checked October 7, 2026.
12. Centers for Medicare & Medicaid Services. National coverage determination: Speech-Language Pathology Services for the Treatment of Dysphagia (170.3) (effective October 1, 2006). “Speech-language pathology services are covered under Medicare for the treatment of dysphagia, regardless of the presence of a communication disability”; “Patients who are motivated, moderately alert, and have some degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy”; “Design all programs to ensure swallowing safety of the patient during oral feedings and maintain adequate nutrition”. Checked October 8, 2026.
13. MedlinePlus Medical Encyclopedia, National Library of Medicine. Swallowing difficulty (review date July 22, 2025). “Difficulty with swallowing is the feeling that food or liquid is stuck in the throat or at any point before the food enters the stomach”; “Damage to the brain may be caused by multiple sclerosis , Parkinson disease , or stroke”; esophageal causes include achalasia, a Schatzki ring, cancer, eosinophilic esophagitis and “Scarring that narrows the esophagus called an esophageal stricture”. “Difficulty swallowing only solids (may indicate a tumor or stricture) suggests a physical blockage such as a stricture or a tumor”; “Difficulty swallowing liquids but not solids (may indicate nerve damage or spasm of the esophagus)”. “Incorrect swallowing may lead to choking or breathing food or liquid into your main airway. This can lead to pneumonia”. Contact a provider right away if “You feel as if you are choking during or after eating or drinking” or “You cough or vomit up blood”. Checked October 8, 2026.
14. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging. 2012;7:287–298. doi:10.2147/CIA.S23404 (PMID 22956864). “In general, a subtle slowing of swallow processes occurs with advancing age”, but “the presence of age-related disease is the primary factor contributing to clinically significant dysphagia in the elderly”; “A primary concern with the overuse of thickened liquids is the risk of dehydration in elderly patients with dysphagia”; the McNeill program “is completed in daily sessions for 3 weeks”. A narrative review.
15. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756–2763. doi:10.1161/01.STR.0000190056.76543.eb (PMID 16269630). Systematic review, “24 articles met inclusion criteria”: “The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%)”; “There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77)”.
16. Wirth R, Dziewas R, Beck AM, Clavé P, Hamdy S, Heppner HJ, et al. Oropharyngeal dysphagia in older persons – from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clinical Interventions in Aging. 2016;11:189–208. doi:10.2147/CIA.S97481 (PMID 26966356). Expert review: “Older patients are frequently unaware of their swallowing dysfunction”; “Most of the features that are suggested to be associated with dysphagia are often not caused by aging per se but a mixture of aging and disease factors”; “Approximately 80% of all patients with PD experience dysphagia at some stage of the disease”; “Inserting a PEG does not prevent aspiration pneumonia in patients with severe dementia”; “Since there are only a few, high-quality studies, the evidence in favor of texture modified foods and thickened fluids, as being effective in preventing or reducing the impact of dysphagia is not strong”. A narrative review, not a systematic one.
17. Tuomi L, Dotevall H, Bergquist H, Petersson K, Andersson M, Finizia C. The effect of the Shaker head-lift exercise on swallowing function following treatment for head and neck cancer: Results from a randomized, controlled trial with videofluoroscopic evaluation. Head & Neck. 2022;44(4):862–875. doi:10.1002/hed.26982 (PMID 35068016). Patients “randomly assigned to intervention (HLE, n = 25) and control (standard dysphagia management, n = 27) groups”. The regimen: “The isometric training included sustained/static head lifts for 60 s three times with rest during 1 min between the lifts”; “This was followed by the isokinetic training which includes 30 consecutive repetitions of head lifts”; “The exercise should be performed three times daily during 8 weeks”. Result: “neither HLE nor standard dysphagia management improved objectively measured swallowing function as evaluated after 8 weeks”, though “Self-perceived swallowing function improved in the intervention group”.
18. American Cancer Society. Swallowing Problems (Managing Cancer-related Side Effects; last revised June 26, 2024). Causes include “Cancer treatments, such as radiation therapy or surgery to the mouth, jaw, throat, or esophagus”; “Many speech pathologists have special training to help people with swallowing problems”; tips include “Sit upright to eat and drink and stay that way for a few minutes after meals” and, unlike NIA’s advice, “Use a straw for liquids and soft foods”; “Go to the emergency room or call 911 if you” are having trouble breathing, have a new or worsening fever, or feel weak or dizzy. Checked October 8, 2026.
19. National Institute of Dental and Craniofacial Research. Dry Mouth (last reviewed October 2024). “when dry mouth persists, it can make chewing, swallowing, and even talking difficult”; “Dry mouth is not a normal part of aging”; “Hundreds of medicines can cause the salivary glands to make less saliva”; “The salivary glands can be damaged if they are exposed to radiation during cancer treatment”; tip: “Sipping water or a sugarless drink during meals. This will make chewing and swallowing easier”. Checked October 8, 2026.
20. MedlinePlus Medical Encyclopedia, National Library of Medicine. Swallowing problems (patient instructions; review date April 27, 2026). Symptoms include “Coughing or choking, either during or after eating” and “Gurgling sounds from the throat, during or after eating”. Home tips: “Sit up as straight as possible when you eat”; “Take small bites, less than 1 teaspoon (5 mL) of food per bite”; “Do not mix solid foods with liquids in the same bite”; “Do not talk and swallow at the same time”; “Sit upright for 30 to 45 minutes after eating”; “Do not drink thin liquids without checking with your provider or therapist first, as thickened liquids may be recommended by the speech pathologist”. Checked October 8, 2026.
21. Communication Health Support Association (consumer site powered by the American Speech-Language-Hearing Association). Swallowing Problems From Head and Neck Cancer Treatment. “You may see an SLP before you have surgery or radiation. The SLP can talk to you about changes you may have swallowing and give you swallowing exercises”; after radiation, “dry mouth or less saliva” and “difficulty opening your mouth wide”; throat surgery “may cause aspiration, when food or liquid enters your airway instead of into your esophagus. Aspiration may lead to pneumonia”. Checked October 8, 2026.
22. MedlinePlus Medical Encyclopedia, National Library of Medicine. Aspiration pneumonia (review date July 25, 2025). “Aspiration pneumonia occurs when food, liquid, or other material from the mouth, nose, or throat is breathed into the airways or lungs, instead of being swallowed”; risk factors include problems with swallowing and “Eating or being fed when not upright”; symptoms include “Coughing up foul-smelling, greenish or dark phlegm (sputum), or phlegm that contains pus or blood”; “Contact your provider, go to the emergency room, or call the local emergency number (such as 911) if you have” chest pain, chills, fever, shortness of breath, “Bluish discoloration of the lips or tongue (cyanosis)” or wheezing. Checked October 8, 2026.
23. Centers for Disease Control and Prevention. Signs and symptoms of stroke (May 19, 2026). Signs include “Sudden confusion, trouble speaking, or difficulty understanding speech”; “Call 9-1-1 right away if you or someone else has any of these symptoms”; in the B.E. F.A.S.T. test for speech, “Ask the person to repeat a simple phrase. Is the speech slurred or strange?”; “The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms”; “Note the time when any symptoms first appear”; “Do not drive to the hospital or let someone else drive you”; a TIA “is a sign of a serious condition that will not go away without medical help”, so “tell a health care team about the symptoms right away.” Checked October 7, 2026.
24. American Speech-Language-Hearing Association. Swallowing Screening (Practice Portal). Screening looks for clinical signs “with a focus on identifying overt signs of aspiration”; “There is no preferred dysphagia screening procedure”; water swallow protocols include the “Yale Swallow Protocol (Leder & Suiter, 2014) including 3 oz. water swallow test”; “It is common for precautions (e.g., dietary precautions, no oral intake) to be put into place while the patient is waiting for further assessment”; “A delay in screening the patient for safety of oral intake can delay administration of oral medications”. Checked October 8, 2026.
25. Prabhakaran S, Gonzalez NR, Zachrison KS, Adeoye O, Alexandrov AW, Ansari SA, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026;57(8):e316–e436. doi:10.1161/STR.0000000000000513 (PMID 41582814). The guideline “replaces the "2018 Guidelines for the Early Management of Patients With AIS" and the 2019 update”; “Key updates include the incorporation of new evidence related to thrombolytic choice and eligibility, determination of eligibility for endovascular thrombectomy, and management of hyperglycemia and dysphagia”.
26. American Heart Association/American Stroke Association. 2026 AIS Guideline Essentials Clinical Slide Series (PowerPoint), slide 29, “Dysphagia in patients with Acute Ischemic Stroke”, with each recommendation’s class (COR): class 1, “In patients with AIS, performing a bedside swallow screening prior to initiation of liquid or food intake is recommended to screen for patients at increased risk for aspiration”; class 2a, “it is reasonable for dysphagia screening to be performed by speech pathologists or other trained health care professionals”; class 2a, for patients who fail or cannot do the screen, “it is reasonable to perform instrumental swallowing assessment, including flexible endoscopic evaluation of swallowing” or videofluoroscopy “to aid in determination of dysphagia severity and aspiration risk”; class 2b, “An oral hygiene protocol may be reasonable to reduce the risk for pneumonia”; class 2b, in non-tracheostomized patients pharyngeal electrical stimulation “may be reasonable to improve swallowing function”; class 2a, after a tracheotomy and ventilator weaning, PES “is reasonable to facilitate readiness for decannulation”. The slide gives each class but not the level of evidence. Checked October 8, 2026.
27. American Heart Association/American Stroke Association. Top Take-Home Messages for Speech Language Pathologists: 2026 AHA/ASA Adult Stroke Rehabilitation and Recovery Guidelines (PDF), written by two members of the guideline writing group. “Speech-language pathologists should screen for dysphagia within 24 hours of admission and before oral intake”; “When dysphagia suspected, a full evaluation using an instrumental swallow study (e.g. video fluoroscopy, FEES), as opposed to a bedside, should be performed”; “Behavioral swallowing treatments are effective for improving swallowing function, food tolerance, and quality of life after stroke”; “Use of strategies such effortful swallow, Mendelsohn maneuver, or tongue resistance training can improve swallowing function”; “Biofeedback and pharyngeal electrical stimulation can be used as adjuncts to behavioral therapy for select patients”. Classes and levels of evidence are not given. Checked October 8, 2026.
28. RadiologyInfo.org (Radiological Society of North America and American College of Radiology). Upper GI x-ray (last reviewed September 1, 2024). The radiologist’s esophagram: “An x-ray examination that evaluates only the pharynx and esophagus is called a barium swallow”; “A radiologic technologist and a radiologist , a physician specifically trained to supervise and interpret radiology examinations, guide the patient through the upper GI series”; “Occasionally, patients find the thick consistency of the barium unpleasant and difficult to swallow”; “The barium may color your stools gray or white for 48 to 72 hours after the procedure”. It describes the radiologist’s barium swallow and upper GI series, not the SLP’s modified barium swallow study. Checked October 8, 2026.
29. Carnaby GD, LaGorio L, Silliman S, Crary M. Exercise-based swallowing intervention (McNeill Dysphagia Therapy) with adjunctive NMES to treat dysphagia post-stroke: A double-blind placebo-controlled trial. Journal of Oral Rehabilitation. 2020;47(4):501–510. doi:10.1111/joor.12928 (PMID 31880338). 53 stroke patients in a subacute rehabilitation hospital were “randomized to receive 3 weeks (15 sessions) of daily MDTP” with NMES, MDTP with sham NMES, or usual care; “Patients were treated for one hour per day for 3 weeks”. “MDTP focuses on swallowing as an exercise” and “Progression during treatment follows an 11 step "food hierarchy"”. “Greater benefit (e.g. reduction in dysphagia severity, improved oral intake, and earlier return to pre-stroke diet) resulted from a program of MDTP alone vs. NMES or UC”; “No adverse events were related to the study interventions”. A small trial; “This study was supported a grant from NIH/ NCMRR”.
30. Park JS, An DH, Oh DH, Chang MY. Effect of chin tuck against resistance exercise on patients with dysphagia following stroke: A randomized pilot study. NeuroRehabilitation. 2018;42(2):191–197. doi:10.3233/NRE-172250 (PMID 29562558). “The patients were randomly assigned to an experimental (n = 11) or a control group (n = 11)”; “The experimental group performed CTAR using the CTAR device”; “Both groups received training on five days a week, for four weeks”; the authors conclude CTAR “is effective in improving the pharyngeal swallowing function in patients with dysphagia after stroke”. A 22-person pilot.
31. Troche MS, Okun MS, Rosenbek JC, Musson N, Fernandez HH, Rodriguez R, et al. Aspiration and swallowing in Parkinson disease and rehabilitation with EMST: a randomized trial. Neurology. 2010;75(21):1912–1919. doi:10.1212/WNL.0b013e3181fef115 (PMID 21098406). Sham-controlled; 60 people with Parkinson’s disease completed it. The device was “set weekly to 75% of the participant’s average maximum expiratory pressure”, and “Each participant trained at home (independent of the clinician) completing 5 sets of 5 repetitions 5 days out of the week” for 4 weeks. “Eleven patients (33%) had improved PA scores following EMST as compared to 5 (14%) in the sham group”. Limits: “the participants had only mild to moderately impaired swallowing”; one author “has potential royalty interest in Aspire Products, LLC”, the maker of the trained device.
32. Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, et al. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology. 2002;122(5):1314–1321. doi:10.1053/gast.2002.32999 (PMID 11984518). The original head-lift (Shaker) exercise trial: “We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program”; “following 6 weeks of real exercise, all 11 patients exhibited a significant improvement in their UES opening” with “resolution of postdeglutitive aspiration and were able to resume oral feeding”; the program “is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening”; “Seven of 27 patients, assigned randomly, participated in a sham exercise before entering the tested exercise program”.
33. National Institute for Health and Care Excellence (UK). Stroke rehabilitation in adults (NICE guideline NG236, published October 18, 2023), recommendations 1.10 and 1.11. “Offer behavioural exercises (for example, chin tuck against resistance) to people with OPD for at least 5 days per week”; “Consider physical stimulation (for example, thermal or tactile stimulation) for people with OPD for at least 5 days per week”; “Give families and carers information on how they can help someone who is coughing or choking while eating or drinking”; if a person cannot take tablets, “review the need for the medication and, if it is still needed, change either its formulation or the route of administration”; support mouth care “because this decreases the risk of aspiration pneumonia”; if a person at risk of aspiration wishes to eat and drink without aids, “respect their choice”. Checked October 8, 2026.
34. Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. The Lancet Neurology. 2006;5(1):31–37. doi:10.1016/S1474-4422(05)70252-0 (PMID 16361020). “306 patients with clinical dysphagia admitted to hospital with acute stroke were randomly assigned to receive usual care (n=102)”, low-intensity therapy “three times weekly for up to a month” or high-intensity therapy “at least daily for up to a month”. “Of patients randomly allocated usual care, 56% (57/102) survived at 6 months free of an abnormal diet compared with 67% (136/204) allocated standard swallowing therapy (relative risk 1.19, 95% CI 0.98-1.45)”; therapy brought “a significant reduction in swallowing-related medical complications (0.73, 0.6-0.9), chest infection (0.56, 0.4-0.8)”; “Compared with usual care and low-intensity therapy, high-intensity therapy was associated with an increased proportion of patients who returned to a normal diet (p=0.04) and recovered swallowing (p=0.02) by 6 months”.
35. International Dysphagia Diet Standardisation Initiative. Complete IDDSI Framework Detailed Definitions 2.2 (PDF, April 2026). IDDSI, “founded in 2013”, describes each level with “simple measurement methods that can be used by people with dysphagia or by caregivers, clinicians, food service professionals or industry to confirm the level a food or drink fits into”. The IDDSI Flow Test with a 10 mL slip-tip syringe after 10 seconds: Level 0 Thin, “Less than 1 mL remaining”; Level 1, “leaving 1-4 mL in the syringe after 10 seconds”; Level 2, “leaving 4 to 8 ml in the syringe after 10 seconds”; Level 3, “leaving > 8 ml in the syringe after 10 seconds”; foods are named “Level 4 Pureed, Level 5 Minced & Moist, Level 6 Soft & Bite-sized” and Level 7 Regular or Easy to Chew. “Sponsors have not been involved with the design or development of the IDDSI framework”. Checked October 8, 2026.
36. International Dysphagia Diet Standardisation Initiative. The IDDSI Framework (the Standard). “The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7”; “The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment”; altering the framework “may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death”. Checked October 8, 2026.
37. International Dysphagia Diet Standardisation Initiative. IDDSI Framework Testing Methods 2.0 (PDF, July 2019). For drinks, “a gravity flow test using a 10 mL slip tip syringe is recommended to quantify the liquid’s flow category (sample remaining from 10 mL after 10 sec of flow)”; “Testing methods for purees, soft, firm and solid foods include: The Fork Drip test, Spoon Tilt test, Fork or Spoon Pressure Test, Chopstick Test and Finger test”; the gaps between fork tines “typically measure 4 mm” (Level 5 particle size), and for Level 6 “a maximum food sample size of 1.5 x 1.5 cm is recommended, which is the approximate size of the adult human thumb nail”. Tips: “Test twice or more to ensure more reliable results”; “Ensure to test the liquid at the intended serving temperature”. Development sponsors listed include thickener makers (“Hormel Thick & Easy (2014-2015)”). Checked October 8, 2026.
38. Logemann JA, Gensler G, Robbins J, Lindblad AS, Brandt D, Hind JA, et al. A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Journal of Speech, Language, and Hearing Research. 2008;51(1):173–183. doi:10.1044/1092-4388(2008/013) (PMID 18230864). “This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically”, each trying all three interventions during the study; “Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture”; “Approximately half (49%) of the participants aspirated on all three of the interventions, whereas 25% of participants did not aspirate on any of the three interventions”; “Patient preference was best for chin-down posture followed closely by nectar-thickened liquids”.
39. Gillman A, Winkler R, Taylor NF. Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia. 2017;32(3):345–361. doi:10.1007/s00455-016-9761-3 (PMID 27878598). The Frazier protocol gives “an option to consume thin (i.e. unthickened) water in-between mealtimes”. “A total of 8 studies were identified for inclusion: 5 randomised controlled trials, 2 cohort studies with matched cases and 1 single group pre-post intervention prospective study”; “low-quality evidence that implementing the protocol did not result in increased odds of having lung complications” and “low-quality evidence that fluid intake may increase”, but only “when the protocol is closely adhered to and patients are carefully selected using strict exclusion criteria, including an evaluation of their cognition and mobility”.
40. National Institute on Aging. Care in the Last Stages of Alzheimer’s Disease. “In the later stages of Alzheimer’s, the person may no longer be able to chew and swallow easily, which increases their risk of choking”; tips: “Don’t use a straw, which may cause more swallowing problems”; “Don’t feed a person who is drowsy or lying down”; upright “for at least 20 minutes after the meal”; “Make sure the person has swallowed before introducing more food”; “Doctors can test the person’s swallowing and give professional advice for how to reduce the risk of choking”. Checked October 7, 2026.
41. Campbell P, Bain B, Furlanetto DL, Brady MC. Interventions for improving oral health in people after stroke. Cochrane Database of Systematic Reviews. 2020;(12):CD003864. doi:10.1002/14651858.CD003864.pub3 (PMID 33314046). “Fifteen RCTs (22 randomised comparisons) involving 3631 participants with data for 1546 people with stroke met the selection criteria”; a multi-component oral care program showed no difference in pneumonia (one trial, 204 people), but “decontamination gel reduced the incidence of pneumonia among the intervention group compared with placebo gel group (OR 0.20, 95% CI 0.05 to 0.84; 1 trial, 203 participants; P = 0.028)”; “We still lack high-quality evidence of the optimal approach to providing OHC to people after stroke”.
42. Cao Y, Liu C, Lin J, Ng L, Needleman I, Walsh T, et al. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database of Systematic Reviews. 2022;(11):CD012416. doi:10.1002/14651858.CD012416.pub3 (PMID 36383760). “We included six RCTs (6244 participants), all of which were at high risk of bias”; the trials “provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia”; professional care “may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months’ follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants)” (low certainty); “No studies evaluated oral care versus no oral care”.
43. American Speech-Language-Hearing Association. Alternative Nutrition and Hydration in Dysphagia Care (Practice Portal). A nasogastric tube is a “Short-term alternative to oral intake (~2 weeks)”; a gastrostomy is an “Option for long-term alternative to oral intake. Does not necessarily preclude oral intake in certain cases”. “The use of ANH may reduce aspiration of food and liquid into the airway; however, individuals with dysphagia who receive ANH remain at risk for aspiration”; after stroke “NG-tubes do not eliminate risk of aspiration”, and early PEG placement “is also associated with lower survival rates”; in dementia tube feeding “is discouraged in those with advanced dementia”. “weaning from tube feeding may be considered given improvements in swallowing abilities”; risk “may be reduced by augmenting ANH with oral hygiene care”; the patient, with their proxy, “chooses to accept or reject use of alternative nutrition and hydration following a shared-decision-making, informed-consent discussion”. Checked October 8, 2026.
44. American Heart Association/American Stroke Association. Stroke Nursing Slide Set for the 2026 AIS Guideline (PowerPoint). Slide 33 (guideline section 5.3, with class and level of evidence): class 1, level B-R, “In patients with AIS, enteral diet should be started within 7 days of admission after an AIS”; class 1, level B-NR, nutritional screening “preferably within 48 hours of admission”; class 2a, level B-NR, “In patients with AIS with dysphagia, it is reasonable to use nasogastric tubes initially for feeding within the first 7 days and to place percutaneous gastrostomy tubes in patients with longer anticipated persistent inability to swallow safely (>2–3 weeks)”. Slide 34 words the PES recommendation differently from the Essentials slide set, as class 2a, level B-R: PES “can be beneficial to reduce dysphagia severity and decrease the risk of aspiration”. Checked October 8, 2026.
45. Dennis MS, Lewis SC, Warlow C; FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet. 2005;365(9461):764–772. doi:10.1016/S0140-6736(05)17983-5 (PMID 15733717). Two FOOD trials of dysphagic stroke patients: “859 patients were enrolled by 83 hospitals in 15 countries into the early versus avoid trial”, where “Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (95% CI -0.8 to 12.5, p=0.09)”; “In the PEG versus nasogastric tube trial, 321 patients were enrolled by 47 hospitals in 11 countries”, and “PEG feeding was associated with an absolute increase in risk of death of 1.0% (-10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05)”. “Early tube feeding might reduce case fatality, but at the expense of increasing the proportion surviving with poor outcome”; “Our data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients”.
46. Code of Federal Regulations, 42 CFR §410.61, Plan of treatment requirements for outpatient rehabilitation services. “The plan is established before treatment is begun by one of the following”, among them “A speech-language pathologist who furnishes the speech-language pathology services”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.” Text as published in the eCFR. Checked October 7, 2026.
47. Code of Federal Regulations, 42 CFR §424.24(c), Outpatient physical therapy, occupational therapy, and speech-language pathology services. When an SLP establishes the plan, “the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case”; “Recertification is required at least every 90 days”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.” Text as published in the eCFR. Checked October 7, 2026.
48. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15: Covered medical and other health services (Rev. 13889, issued July 30, 2026), section 220.3. “The progress report provides justification for the medical necessity of treatment”; “The minimum progress report period shall be at least once every 10 treatment days.” Checked October 7, 2026.
49. Centers for Medicare & Medicaid Services. Jimmo settlement. The Jimmo Settlement Agreement (January 2013) “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met)”; coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Checked October 7, 2026.
50. American Speech-Language-Hearing Association. Telepractice (Practice Portal). “Use of telepractice should be of equal quality to in-person services”; informed consent includes “the client’s right to request in-person services at any time”; “Clinicians should verify state licensure/certification requirements in the state from which the clinician provides services as well as the state in which the client receives services prior to initiating services.” Checked October 7, 2026.
51. Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30(4):744–748. doi:10.1161/01.STR.30.4.744 (PMID 10187872). “We prospectively assembled an inception cohort of 128 hospital-referred patients with acute first stroke”; at presentation a swallowing abnormality was found “clinically in 65 patients (51%; 95% CI, 42% to 60%) and videofluoroscopically in 82 patients (64%; 95% CI, 55% to 72%)”; “At 6 months after stroke, 97 of the 112 survivors (87%; 95% CI, 79% to 92%) had returned to their prestroke diet”, yet “Clinical evidence of a swallowing abnormality was present in 56 patients (50%; 95% CI, 40% to 60%)”; “26 patients (20%; 95% CI, 14% to 28%) suffered a chest infection”. The authors ask that the findings be validated (“These findings require validation in other studies”).
52. Hutcheson KA, Lewin JS, Barringer DA, Lisec A, Gunn GB, Moore MW, et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer. 2012;118(23):5793–5799. doi:10.1002/cncr.27631 (PMID 23640737). Case series: “Twenty-nine patients previously treated with radiotherapy (38%) or chemoradiotherapy (62%) were included (median years post-treatment: 9, range: 5–19)”; “Twenty-five (86%) developed pneumonia, half requiring hospitalization”; “Ultimately 19 (66%) were gastrostomy dependent”; severe dysphagia “may develop or progress years after radiation-based therapy”. The authors add that the small number of cases suggests “severe, late dysphagia is uncommon”.
53. Centers for Medicare & Medicaid Services. Telehealth (Medicare.gov). “Through December 31, 2027, Medicare covers telehealth services that you can get from anywhere in the U.S., including your home”; the examples listed include speech therapy, cognitive assessments and “Caregiver training services”; after the Part B deductible you pay 20% of the Medicare-approved amount, and “For most telehealth services, you’ll pay the same amount that you would if you got the services in person”; Medicare Advantage plans “may offer more telehealth benefits than the basic coverage in Original Medicare.” Checked October 7, 2026.
54. Centers for Medicare & Medicaid Services. Home health services (Medicare.gov). Home health care helps you “maintain your current condition or level of function, or slow your rate of decline”; covered services include “speech-language pathology services (if you meet certain conditions)”; you must need part-time or intermittent skilled services and be homebound: “Leaving your home isn’t recommended because of your condition or you have trouble leaving your home without help” and “You’re normally unable to leave your home and leaving takes a lot of effort”; “You can still get home health care if you attend adult day care”; a provider “must see you in person and confirm you need home health care”; “You pay nothing for covered home health services.” Checked October 7, 2026.
55. Centers for Medicare & Medicaid Services. Skilled nursing facility care (Medicare.gov). Covered services include “Speech-language pathology services (if they’re needed to meet your health goal)”; Medicare covers SNF care only after “a prior medically necessary inpatient hospital stay of at least 3 days in a row”; eligibility includes needing skilled care “to improve or maintain your current condition, or to prevent or delay it from getting worse”; in 2026, “Days 1–20: You pay $0 each day after you pay the $1,736 deductible”; “Part A limits SNF coverage to 100 days in each benefit period.” Checked October 7, 2026.
56. Centers for Medicare & Medicaid Services. Inpatient rehabilitation care (Medicare.gov). Part A covers care in an inpatient rehabilitation facility, including rehabilitation services such as speech-language pathology; “Your health care provider must certify that you have a medical condition requiring intensive rehabilitation, continued medical supervision, and coordinated care from your providers”; in 2026, “Days 1-60: After you pay the $1,736 deductible you pay $0 each day.” Checked October 7, 2026.
57. Centers for Medicare & Medicaid Services. Therapy services. The Bipartisan Budget Act of 2018 repealed the outpatient therapy caps and “preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record”; “For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined”; “the MR threshold is $3,000 for PT and SLP services”, and “not all claims exceeding the MR threshold amount are subject to review.” Checked October 7, 2026.
58. Medicaid.gov (Centers for Medicare & Medicaid Services). Mandatory & optional Medicaid benefits. “States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process”; mandatory benefits include home health services and nursing facility services; optional benefits include “Speech, hearing and language disorder services.” Checked October 7, 2026.
59. HealthCare.gov (Centers for Medicare & Medicaid Services). What Marketplace health insurance plans cover. “All plans offered in the Marketplace cover these 10 essential health benefits”, among them “Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)”; “Specific services covered in each broad benefit category can vary based on your state’s requirements.” Checked October 7, 2026.
60. Veterans Health Administration. VHA Directive 1170.02(1): VHA audiology and speech pathology services (December 9, 2020; amended July 19, 2022). The directive covers “disorders of hearing, tinnitus, balance, speech, language, voice, fluency, cognitive and swallowing”; “Audiology and speech pathology services are standard medical benefits available to all enrolled Veterans.” Checked October 7, 2026.
61. Flowers HL, Silver FL, Fang J, Rochon E, Martino R. The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. Journal of Communication Disorders. 2013;46(3):238–248. doi:10.1016/j.jcomdis.2013.04.001 (PMID 23642855). Chart review of 221 patients: “Estimates of the incidence of dysphagia, dysarthria, and aphasia were 44% (95% CI, 38-51), 42% (95% CI, 35-48) and 30% (95% CI, 25-37), respectively.” “The highest co-occurrence of any two impairments was 28% (95% CI, 23-34) for the presence of both dysphagia and dysarthria.”
62. American Speech-Language-Hearing Association. ASHA clinical specialty certification. A Board Certified Specialist (BCS) has demonstrated advanced knowledge and skills in an area; “Specialty certification is not required to practice in any area within the Audiology or Speech-Language Pathology Scopes of Practice”; “Specialty certification is currently available through” five boards: the “American Audiology Board of Intraoperative Monitoring”, the “American Board of Augmentative and Alternative Communication”, the “American Board of Child Language and Language Disorders”, the “American Board of Fluency and Fluency Disorders” and the “American Board of Swallowing and Swallowing Disorders.” Checked October 7, 2026.
63. American Speech-Language-Hearing Association. Information about ASHA certification. The CCC is “a nationally recognized professional credential that represents a level of excellence in the field”; holders “have voluntarily met rigorous academic and professional standards, typically going beyond the minimum requirements for state licensure.” Checked October 7, 2026.
64. American Speech-Language-Hearing Association. Audiology and speech-language pathology certification. ASHA’s public tool lets anyone “Verify the status of an individual’s Certificate of Clinical Competence in Audiology (CCC-A) or Speech-Language Pathology (CCC-SLP).” Checked October 7, 2026.

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