Recommendations For The Future

The patient’s estimated length of stay in the acute stroke unit is 5 days. Once they are medically stable and acute investigation treatment has been completed, they will be discharged to one of the following places:
  • To their previous residence with or without support services if they have made a rapid recovery.
  • Patients requiring on-going rehabilitation can be transferred to the Older Persons Health (OPH) or Rehab Plus wards or general hospital ward.
  • Patient may be transferred to a rest home or hospital level nursing care facility when if not a suitable candidate for rehabilitation due to severeness of co-morbid conditions.

(Barber, Fink, Gommans, Hanger, & Baker, 2006).

Dysphagia management will need to continue in these environments therefore it is critical for consultation to occur with the patient’s family/carers and their next SLT prior to the patients move in order to provide information and advice about how to manage dysphagia in a patient with bilateral hemispheric stroke.

Advice to future SLT:

It will be important to express to the patients next SLT, that recovery of some swallowing function in a patient with bilateral hemispheric stroke is possible. However, these patients will require longer rehabilitation than patients with unilateral stroke (Neumann, 1993). In addition, it will be important to recognise how the patients co-morbid conditions will effect and or limit the therapy approaches that could be used with a patient with bilateral hemispheric stroke. Therapy approaches that may be suitable for a patient with bilateral hemispheric stroke:
Short term: Compensatory Strategies to assist oral intake (no change to the physiology of the swallow).
  • Posture modifications

The effects of postural changes on swallowing should be identified for each individual during VFS to determine the safest and most efficient mechanism for swallowing. A patient with bilateral stroke is likely to have damage to several cranial nerves which impacts on the swallowing function of more than one stage of the swallowing process. As a result, a combination of posture modifications may need to be used or posture modifications may need to be used in conjunction with some of the other compensatory measures to produce the safest swallow.
  • Swallowing manoeuvres

The supraglottic swallow and supra-supraglottic swallow manoeuvres are techniques used to facilitate protection of the airway by performing various breath hold techniques prior to swallowing. Patients with bilateral hemispheric stroke are at the highest risk for aspiration therefore these techniques may be useful to help reduce the risk of aspiration when swallowing.
  • Modifying food or liquid consistency

Modifying the consistency of a patients diet should be the final option considered before long-term tube feeding is recommended. Changing the consistency of a patient’s diet can have a large effect on the patient’s quality of life and therefore must be carefully considered and discussed with the patient and their family/caregivers before implementing this strategy. Click here to view the NZ standards for texture modified fluids and solids.
For further information on compensatory or long term therapy strategies, see Chapters 17 and 18 from Dyphagia following Stroke. Daniels and Huckabee, 2008.
Recommendations for Feeding
If a patient is able to swallow safely but either requires assistance in eating or drinking, or requires a texture modified diet, the following points are recommended to help make eating a pleasurable experience.

  • Ensure food is at the appropriate temperature for eating.
  • Make the food look appetising.
  • Make the food smell nice.
  • Make the food taste good.
  • Let the patient self feed if they are capable of it as it will give them more control over the swallowing process.
  • Maintain any important social aspects of eating such as conversation if the patient can manage this.

(Groher and Crary, 2010. Daniels & Huckabee, 2008).

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