Swallowing, a process dedicated to moving the food bolus to the stomach, entails both mechanical and neurological support, which itself is both a sophisticated and synchronic activity. Although swallowing may appear deceptively simple, it is in fact a highly intricate neuromuscular process that relies on precise coordination among cortical, subcortical, and brainstem structures. Cortical regions initiate and regulate the voluntary oral phase, while subcortical circuits fine-tune motor control. The brainstem central pattern generator integrates sensory input with cranial nerve activity (V, VII, IX, X, XII) to orchestrate rhythmic, involuntary movements of the pharynx and oesophagus. This seamless interplay ensures airway protection, efficient bolus transit, and safe progression from voluntary to reflexive phases. Any disruption in these interconnected neural pathways can compromise swallowing efficiency and lead to dysphagia (Walton & Silva, 2024). Impairments arising from neurological, physiological, or anatomical factors can result in atypical swallowing patterns. The consequent aspiration may lead to life-threatening conditions such as pneumonia or manifest as struggling behaviours that render the swallowing process more laborious and fatiguing (Panara & Padalia, 2020). Dysphagia is a highly prevalent condition ranging from 2% to 16% among the general population and 40% in hospitalised cases, with a higher risk in the older population (Baijens et al., 2016). In the Indo-Pak subcontinent, recent studies highlight a significant prevalence of dysphagia among older adults, with community-based surveys in India having reported rates ranging up to 36.6%. Although direct prevalence data from Pakistan remain limited, the presence of similar risk factors – such as ageing, stroke, and neurological disease – suggests that comparable rates are likely within Pakistani populations (Dodderi et al., 2024). A very high prevalence of 38% to 53% in post-stroke cases has been reported in Pakistan (Akhtar et al., 2023). Dysphagia, commonly known as swallowing difficulty, is a condition in which the safe passage of food from the oral cavity to the stomach is interrupted. Dysphagia can result from neurological disorders like stroke, multiple sclerosis, Parkinson’s and neurological trauma; muscle dysfunction like oesophageal spasm, dystrophy or achalasia; or structural abnormalities in the throat and oesophagus including neoplasms, stricture, diverticulum etc (Wei et al., 2023). Literature revealed that among the four dysphagia stages, including oral preparatory, oral, pharyngeal, and oesophageal phases, the cardiovascular accidents (CVAs) frequently affect the first three stages by reducing sensations, conscious control of mastication, eliciting swallowing reflex, et cetera. Disorders or lesions affecting these cortical areas may result in abnormal lip closure, incoordination, delays, and often a complete absence of gag reflex (Abubakar & Jamoh, 2017). Among the four identified stages of swallowing, the oropharyngeal phase is more frequently affected and related to aspiration, severe dietary, nutritional, and pulmonary difficulties. Cases with dysphagia often remain neglected (Clavé & Shaker, 2015). An atypical swallowing pattern may result in aspiration and can lead to life-threatening conditions like pneumonia or may result in struggling behaviour, making the process more laborious and tiring (Panara & Padalia, 2020). Dysphagia is also associated with a decrease in quality of life, dehydration, malnutrition, and social isolation, necessitating dysphagia screening (Andrade et al., 2018). Literature revealed that among the speech-language pathologists’ (SLPs’) perceptions regarding dysphagia, they highlighted it as challenging with complications in the acute phase following stroke (Minchell et al., 2022). As dysphagia can lead to life-threatening situations, there is a need for further study (Dziewas et al., 2021). Although SLPs’ work in dysphagia in South American countries, including Brazil, has been reported as impressive (Mendes et al., 2022), recent surveys from both Pakistan and India reveal that many SLPs lack sufficient knowledge, training, and standardised practices in the management of dysphagia, hence dysphagia cases form a very small percentage of their overall workload with 79% having less than 5 years of dysphagia-related practice. This underscores the urgent need for professional development initiatives (Akhtar et al., 2023; Rangarathnam & Desai, 2020). Another Indian study revealed that SLPs do not receive enough chances to work in dysphagia multidisciplinary teams (Devan & Mk, 2023), although there are several benefits of working in multidisciplinary teams (Brammer & Vicari, 2020). A previous study reveals that SLPs in Pakistan demonstrate limited and variable knowledge of dysphagia aetiologies, often recognising neurological causes like stroke and Parkinson’s (Akhtar et al., 2023). Also, according to Haider and Zubair (2022), in Pakistan, the SLPs’ most preferred intervention approaches for dysphagia management are primarily behavioural and compensatory techniques, while advanced instrumental methods are marred by limited use. Dysphagia is a highly prevalent condition with significant health implications, particularly in post-stroke populations where rates in Pakistan have been reported as high as 38% – 53% (Akhtar et al., 2023). Its management is critical, given the life-threatening complications such as aspiration pneumonia, malnutrition, and dehydration (Dziewas et al., 2021). Effective care requires specialised knowledge, skills, and clearly defined roles for SLPs, yet evidence from the Indo-Pak region highlights persistent limitations in current practice. Studies reveal that many SLPs lack adequate training, standardised protocols, and opportunities to work within multidisciplinary teams, all of which are essential for optimal dysphagia management (Devan & Mk, 2023). These gaps underscore the pressing need to investigate SLPs’ perspectives regarding their workload, understanding of dysphagia aetiologies, and preferred management approaches. Such exploration will help identify deficiencies in knowledge, training, and practice, thereby guiding the development of targeted professional development initiatives and standardised guidelines. Strengthening dysphagia care in this way is vital to improving patient outcomes in Pakistan and similar contexts. Moreover, this study holds significant importance as it will contribute to prevention, enhance management strategies, and support information dissemination to both clinical populations and the research community.

The current qualitative exploratory research was conducted at Riphah International University over a period of 12 months, from 01 January 2023 to 31 December 2023. The study was conducted after obtaining approval from the Research Ethics Committee of Riphah International University, Lahore.

The results of this study indicate that the majority of the respondent SLPs were females (54%) and held a master’s degree in speech-language pathology. The mean age of the respondents was 38.45 ± 9.29 years, with a mean experience of 12.95 ± 7.73 years. The engagement hours of practice per day worked out as 8 h/day, while the average number of dysphagic patients seeking support was 7 (Table 1).

Table 1 shows that 63.6% of SLPs served both children and adults, while 18.2% served children or adults alone. Traditional, non-invasive strategies dominated dysphagia intervention. Analysis suggests that SLPs’ dysphagia practice is shaped by three different focuses that include finding issues with the nervous system, navigating the evidence through formal and informal means, and negotiating the barriers imposed by the system, such as access and the non-availability of technological support. The following paragraph will reflect upon the qualitative findings that have emerged from Table 1. As a primary finding, the participants constructed dysphagia primarily as a problem of some neurological or bodily effect. When describing their caseloads, SLPs reported acquired neurological conditions – stroke, Traumatic Brain Injury (TBI), brain tumours, Parkinsonism, dementia, and Alzheimer’s and so on, with oropharyngeal dysphagia presentations. Secondly, intervention choices revealed a mismatch between standard options and available resources. While SLPs named electrical stimulation as the ‘current international trend’, their daily practice relied on what they called ‘traditional strategies’: postural management, manoeuvres, counselling, nutritional management, endoscopic intervention, and bedside swallow evaluations. Thirdly, participants described their work as necessarily collective but isolated in reality. Referrals to multidisciplinary teams were valued in principle; however, access to them was questioned. SLPs recommended awareness campaigns as a possible solution, targeting both professional training and family or caregiver education. Thus, ‘limitation of access’ was not merely a logistical barrier; it functioned as a rationing mechanism that SLPs navigated daily.

The present study is situated within the Pakistani context, where allied health professions such as speech-language pathology remain in their formative stages. While nursing has long been established, disciplines including occupational therapy, speech-language pathology, and vocational therapy are only beginning to gain recognition within educational and clinical faculties. Against this backdrop, the study sought to identify key factors contributing to dysphagia-like symptoms, particularly within the sociocultural realities of Pakistan. Structural challenges such as poverty, inadequate health and safety measures, political extremism, and volatile border conditions were anticipated to play a role in the neurological conditions that predispose individuals to dysphagia. At the same time, the study explored the intervention options currently available to dysphagic clients, recognising that the profession’s emerging status necessitates a clearer understanding of both workload distribution and preferred management approaches among clinicians. By situating these findings within the broader discourse on healthcare development, the study underscores the urgent need to establish foundational knowledge about professional practice patterns and intervention preferences in Pakistan, thereby contributing to the global conversation on dysphagia care in resource-constrained settings. This discussion will explore how the findings of the present study align with, extend, or diverge from existing literature. In the following sections, key results are examined in relation to prior evidence, highlighting areas of convergence that strengthen the credibility of the study as well as points of departure that invite further reflection. By situating the findings within established scholarship, the discussion aims to demonstrate both the continuity of evidence and the unique contributions this research makes to the broader understanding of dysphagia management. In terms of aetiologies, cerebrovascular accidents (CVA), TBI, brain tumours, and other neurological disorders, including Parkinson’s disease, were identified as leading causes of dysphagia in Pakistan. This finding is consistent with the earlier study conducted by Martino et al. (2005). Dysphagia has also been reported as an important non-motor feature of Parkinson’s disease (Kwon & Lee, 2019). Because dysphagia can arise from multiple aetiologies that are often difficult to predict and ascertain, neurological considerations remain the primary source of referrals made by professionals, with approximately 37% – 55% of cases resulting from stroke. Similarly, Menon (2022) reported that neurological causes, followed by pathological causes such as head and neck tumours, are common aetiologies, a finding echoed in the current study where one respondent stated: ‘It can be due to stroke or due to any kind of brain tumour’. Stroke has consistently been identified in the literature as a leading contributor to dysphagia-like symptoms, with reduced laryngeal elevation and delayed pharyngeal reflex among the common mechanisms that can also result in aspiration (Zhang et al., 2016). This aligns with the present study, where a respondent noted: ‘We usually see post-stroke dysphagia patients presenting with laryngeal dysphagia’. In addition, TBI cases were reported, with another respondent stating: ‘Mainly referrals are stroke patients of elderly ages and occasional accidental cases are referred to us’. Literature further supports this, revealing dysphagia in up to 93% of TBI cases (Howle et al., 2014). Literature reports dysphagia prevalence rates of 52% for tumours involving the pharynx, 28% for laryngeal tumours, and 21% for oral tumours (Cristofaro et al., 2021). However, the current study identified brain tumours as one of the leading causes. This difference may be explained by referral patterns, as patients with laryngopharyngeal and oral tumours typically present to otolaryngologists rather than to SLPs, thereby influencing the distribution of cases observed in this study. In the current study, one respondent observed: ‘We have a geriatric population with Parkinson’s, motor neuron disease’. Ageing itself, along with skeletal fragility, reduced daily life activities, and chronic illness, has been identified as a major risk factor for dysphagia (Dellis et al., 2018). Similar associations between age and swallowing difficulties have been consistently reported in the literature. For example, Dellis et al. (2018) reported a 15% prevalence among individuals aged 65 years and older. Age-related changes such as reduced muscle mass, decreased tissue elasticity, and diminished overall strength have been highlighted as contributing factors to dysphagia-like symptoms (Cichero, 2018). Moreover, dementia prevalence increases sharply with age, doubling every 5 years beyond 65 years (Hugo & Ganguli, 2014). Dysphagia is particularly common in dementia, with severe Alzheimer’s disease cases showing prevalence rates of 84% – 93% (Mira et al., 2022). Reflecting this, participants in the present study also identified dementia as a leading cause of dysphagia, especially in the preparatory and oral phases. As one respondent noted: ‘At times patients with dementia come for rehabilitation. Usually, the reason behind it is their forgetfulness and not physiological’. With regard to the second theme, current trends in interventional strategies, most participants expressed interest in electrical stimulation as a potential option, as reflected in the statement: ‘Electrical stimulation is an option, which we are considering using’. At present, VitalStim therapy is rarely employed in hospitals across Pakistan, largely due to barriers such as scepticism regarding its benefits and limited training opportunities (Farooq et al., 2023). Nevertheless, evidence demonstrates that neuromuscular electrical stimulation is an effective intervention for the rehabilitation of dysphagia following stroke (Jamil et al., 2024). In the current study, participants acknowledged awareness of this technique, noting: ‘Have also read about electrical stimulation and its usefulness, however not yet used’. This contrasts with the literature, which indicates that neuromuscular electrical stimulation, when used as an adjunct to traditional therapy, can provide significant relief for tube-fed dysphagia patients (Scarponi et al., 2015) and may also be beneficial in paediatric cases (Budkowska & Kolanowski, 2025). These findings highlight a gap between evidence-based practice and clinical application in Pakistan, underscoring the need for greater training, awareness, and institutional support to integrate electrical stimulation into routine dysphagia management. In the current study, the third theme which emerged among the management options was traditional strategies, with the subthemes of postural management and manoeuvres topping the list as depicted by the statement ‘In clinical practice we work on their postural management, guide about swallowing manoeuvre, and with that diet modification. While working directly with patient and attendants involved indirectly’. This follows literature, which indicates that postural changes can help dysphagia patients move food boluses safely (Alghadir et al., 2017). Literature also indicates that postural management, along with electroacupuncture and traditional therapy, improves dysphagia (Wu et al., 2024). However, this is not the case in Pakistan, as stated by a participant ‘In clinical practice we use different manoeuvres with a diet modification and postural management to treat the patient mostly’ where neuromuscular electrical stimulation is rarely being used, however the therapists are ambitious is using this technique as stated by participants ‘Have also read about electrical stimulation and its usefulness, however not yet used’. Another subtheme, endoscopic intervention, came up; however, as stated, ‘We refer our patients for any endoscopic intervention to ENT specialists’. SLPs in Pakistan usually refer cases to Ear, Nose, Throat (ENT) surgeons, and only very few SLPs do Fibre-optic Endoscopic Evaluation of Swallowing ‘FEES’ by themselves. This is in contrast to American Speech-Language-Hearing Association (ASHA) guidelines, where SLPs with ample training and competence are considered qualified to perform FEES (Flexible Endoscopic Evaluation of Swallowing, 2025). Another theme that emerged was awareness campaigns for training. Participants indicated that ‘Trainings or refresher courses for SLPs are very important’. This is quite evident as very few SLPs are doing endoscopic evaluations due to a lack of training. Hence, refresher courses are no doubt useful to add the missing skills and knowledge in professionals (Schwid et al., 2019). Similarly, awareness campaigns for family and caregivers were another subtheme as indicated by the participants ‘Definitely, family members, attendants, people who are feeding the patient need to be trained because they play a very important role and this is possible with awareness programs’. There is no doubt that better awareness of caregivers is important to ensure proper patient care, avoid complications and improve the quality of life (Demetriou et al., 2025). Limitation of access to services was another subtheme which was highlighted with subthemes of physical access and online access, as indicated by participants ‘In Pakistan’s far-flung areas there is dearth of professionals and hence access to rehab services is limited’. This is a problem faced in developing countries due to habitation in far-flung regions, a shortage of trained SLPs, prolonged travel to receive services, and a shortage of transport, in addition to economic issues (O’Callaghan et al., 2005). Though online services were provided frequently during the coronavirus disease 2019 (COVID-19) period, participants indicated:

Though the number of SLPs opting for online therapy is multiplying, literature also reveals barriers in implementing online services, including failure of technology. Hence, it is recommended to assess each individual case before deciding on physical or online sessions (Anghel, 2021). Hence, the current study illuminates SLPs’ perspectives on dysphagia management, revealing how systemic constraints and professional identities intersect to shape clinical practice. Rather than presenting dysphagia care as a purely technical skill, the findings highlight its socially situated nature, where workload pressures, limited standardised training, and institutional contexts converge to influence decision-making. These insights extend regional surveys by adding depth to our understanding of preferred intervention approaches, while also challenging assumptions about uniformity in practice. Importantly, the study underscores that clinicians’ interpretations of dysphagia care are embedded within broader healthcare structures, linking individual experiences to systemic debates on training and resource allocation. Although purposive sampling and reliance on a self-developed tool may limit transferability, the reflexive stance adopted and transparency in reporting strengthen credibility. By situating these findings within ongoing calls for national guidelines and professional development, the study contributes to a growing body of work advocating systemic reforms alongside individual clinician training. In doing so, it not only addresses immediate practice concerns but also invites readers to reflect on the wider implications for dysphagia care in the Indo-Pak context.

In conclusion, it can be divulged that although services for individuals with dysphagia are available, they remain limited and are concentrated primarily in major urban centres. The service delivery models are not standardised, as the research indicates. The interventions and therapies still rely on traditional supports and need to be made robust and evidence-based. There is a dearth of technological reliance; thus, standardised tools and equipment are strongly mandated. The study concludes that there is a higher workload of SLPs, which may be because of shortages of professionals, increased incidence of aetiological factors leading to dysphagia, extended periods of treatment and poorer awareness. A multidisciplinary team approach and the need for awareness campaigns were considered essential. An extensive study is recommended to identify the existing technological support available to speech professionals in hospitals, using a larger sample. Further, the efficacy of online therapy options for dysphagic clients, especially to reach out to patients at some distance, may be explored. In summary, referring to this study, the professionals (SLPs) do not have many options available to them when it comes to managing a dysphagic client; hence, their reliance on traditional and biomedical approaches is increased. In the aftermath, they often resort to non-invasive procedures, which, although safer, tend to be less effective and more time-consuming. Further to this, constraints within the system hamper their navigational options, which seriously call for technology-based infrastructure.