Aclear relationship exists between stroke, dysphagia, Clinical Assessment of Swallowing and Prediction of Dysphagia Severity.

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1 Research Clinical Assessment of Swallowing and Prediction of Dysphagia Severity Stephanie K. Daniels Department of Veteran Affairs Medical Center and Tulane University School of Medicine, New Orleans Colleen P. McAdam Alton Ochsner Medical Foundation, New Orleans Kevin Brailey Anne L. Foundas Department of Veteran Affairs Medical Center and Tulane University School of Medicine, New Orleans Dysphagia with aspiration is prevalent in acute stroke; however, noninvasive clinical screening assessments to identify patients at risk of developing aspiration are limited. This study was undertaken to determine whether risk factors detected in the clinical examination approximated the videofluoroscopic swallow study (VSS) in identification of dysphagia severity. Six clinical features dysphonia, dysarthria, abnormal volitional cough, abnormal gag reflex, cough after swallow, and voice change after swallow were assessed by means of an oropharyngeal evaluation and a clinical swallowing examination. Clinical assessments and VSS were completed on consecutive stroke patients (n = 59) within 5 days of hospital admission. The VSS was scored on a scale of 0 to 4 (0 = normal, 1 = mild, 2 = moderate, 3 = moderate-severe, 4 = severe dysphagia). Results showed that the presence of at least 2 of the 6 clinical features consistently distinguished patients with moderate to severe dysphagia from patients with mild dysphagia/normal swallowing. These data demonstrate that this clinical dysphagia screening tool can provide objective criteria for the need for VSS in acute stroke patients. Aclear relationship exists between stroke, dysphagia, and the development of aspiration pneumonia. The occurrence of dysphagia following stroke is approximately 30% (Groher & Bukatman, 1986), with estimates of 30% to 70% of poststroke patients aspirating as identified by videofluoroscopic swallow study (VSS; Horner & Massey, 1988; Linden & Siebens, 1983). In addition, 50% of stroke patients with dysphagia severe enough to warrant a VSS develop aspiration pneumonia (Johnson, McKenzie, & Sievers, 1993). The development of pneumonia is 7.5 times greater in stroke patients who aspirate than in those who do not (Schmidt, Holas, Halvorson, & Reding, 1994). The mortality rate is 43% in hospitalized elderly patients who develop pneumonia (Gonzalez & Calia, 1975). Consequently, the complications of aspiration, such as pneumonia, render stroke patients acutely ill; this may increase the length of hospitalization and delay rehabilitation efforts designed to improve stroke outcome. Silent aspiration, which is the subglottic penetration of a bolus without elicitation of a cough reflex, occurs in approximately 40% of patients with dysphagia who aspirate and is generally not identifiable on clinical examination (Logemann, 1983; Splaingard, Hutchins, Sulton, & Chaudhuri, 1988). Decreased pharyngeal and supraglottic sensation have been documented in stroke patients (Aviv et al., 1996) and may affect overt response to aspiration. Ott, Hodge, Pikna, Chen, and Gelfand (1996) reported a 66% incidence of inability to determine pharyngeal dysfunction with clinical evaluation alone, although their clinical examination was limited to observation of swallowing without an oropharyngeal examination. Linden, Kuhlemeier, and Patterson (1993) reported that the presence of nine clinical parameters, including recumbent posture, dysphonia, aphonia, wet hoarseness, decreased laryngeal excursion, wet spontaneous cough, decreased ability to swallow secretions, decreased palatal gag, and American Journal of Speech-Language Pathology Vol /97/ American Daniels Speech-Language-Hearing McAdam Brailey Association Foundas 17

2 harsh or breathy phonation, identified aspiration with 66% accuracy. The length of time postonset of dysphagia was not indicated in these studies, and the clinical populations studied were not limited to stroke patients. Other studies have evaluated the utility of clinical water swallowing examinations to identify dysphagia and aspiration. In these studies, neurological diagnosis (Nathadwarawala, McGroary, & Wiles, 1994), acuteness of stroke (DePippo, Holas, & Reding, 1992, 1994), and confirmation of dysphagia with VSS (Barer, 1989; Gordon, Hewer, & Wade, 1987; Odderson, Keaton, & McKenna, 1995) varied. In general, however, a water swallow examination has limited application to the accurate assessment of aspiration in that silent aspiration cannot be identified. Although VSS is considered the gold standard for the accurate assessment of oropharyngeal dysphagia, particularly with reference to silent aspiration, it is important to develop objective criteria to determine which stroke patients are at risk of aspiration and, therefore, should undergo a videofluoroscopic procedure. Clinical features evident during the first few days poststroke may identify stroke patients at risk for the development of aspiration pneumonia, thus facilitating early intervention to prevent this complication. Most of the previous investigations have evaluated chronic stroke patients 1 to 24 months postonset (DePippo et al., 1992, 1994; Horner & Massey, 1988; Linden et al., 1993; Linden & Siebens, 1983), and only two studies (Daniels et al., in press; Kidd, Lawson, Nesbitt, & MacMahon, 1993) have investigated the clinical features of aspiration in the acute stroke population using VSS. Kidd and colleagues (1993) evaluated 60 patients admitted with suspected unilateral stroke, although only 50% had stroke confirmed by neuroimaging studies. Dysphagia, as detected by VSS, occurred in 90% of the total stroke group, with aspiration evidenced in 42% of the total group. Clinical assessment within 3 days of admission revealed that decreased pharyngeal sensation, dysphagia on a water swallow test, and stroke severity were significantly related to the occurrence of aspiration on VSS. In order to determine the frequency of aspiration and clinical predictors of dysphagia in stroke, Daniels and colleagues (in press) evaluated consecutively admitted acute stroke patients (n = 55). Evaluation of the oropharyngeal mechanism, clinical swallowing examination, and VSS were completed within 5 days of the acute stroke. Using VSS, dysphagia was identified in 65% of these patients, with aspiration occurring in 38% of the total group. Daniels et al. (in press) determined that the presence of the clinical features of dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, voice change after swallow, and cough after swallow were highly predictive of patients at risk of aspiration. Given the high incidence of dysphagia and aspiration, particularly silent aspiration, in acute stroke, and given the lack of a valid clinical screening examination to determine the need for VSS, this investigation was designed to determine whether the six risk factors previously identified by Daniels et al. (in press) approximated the VSS in identification of dysphagia severity. As previously identified, concurrent findings of two of the six clinical features (abnormal volitional cough and cough after swallow) had the best predictive value for identification of aspiration (Daniels et al., in press); therefore, we posited that the presence of any two or more of the clinical features (dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow) would predict at least a moderate dysphagia on VSS, and the presence of one or none of these clinical features would predict mild dysphagia or normal swallowing. Methods Subjects Fifty-nine patients consecutively admitted to the Veterans Affairs Medical Center in New Orleans with a new neurological deficit were recruited to participate. Nonhemorrhagic stroke was confirmed by documentation of acute infarct by either computed tomography (CT) or magnetic resonance imaging (MRI) scan in the patients studied. Twenty-two patients presented with unilateral left hemispheric damage, 18 presented with unilateral right hemispheric damage, 13 presented with bilateral hemispheric lesions, and 6 presented with brainstem lesions. Obtunded and agitated patients were excluded from the study, as well as those with a prior history of oropharyngeal dysphagia, oropharyngeal structural damage, or neurological disease other than stroke that may produce dysphagia. Language and mental status evaluations were not completed on all patients. The Western Aphasia Battery (WAB; Kertesz, 1982) and Mini-Mental Status Examination (MMSE; Folstein, Folstein, & McHugh, 1975) were administered to further assess language and mental status function when indicated by an informal clinical evaluation by the speech-language pathologist or neurologist. Using these evaluations and an aphasia quotient cut-off score of 93.8 for the WAB and a cut-off score of 26 on the MMSE, 11 of the patients presented with aphasia and 9 presented with cognitive deficits. Mean patient age was 66 years (SD 11; range years), and all patients were male. Procedures All patients underwent a clinical evaluation, consisting of an oropharyngeal examination and a clinical swallowing assessment, as well as a VSS within 5 days of admission. The average time between the clinical and fluoroscopic swallowing assessments was 48 hours. Neuroimaging studies were obtained on patient admission. CT or MRI scans were repeated within 2 weeks on patients with initial negative scan results. Neuroimaging studies were reviewed and lesions were localized by a board-certified neurologist using Damasio and Damasio s (1989) technique, which uses standardized templates of axial CT/MRI sections at various angles to the canthomeatal line. Oropharyngeal Examination An oropharyngeal assessment, which included examination of gag reflex, volitional cough, speech, and voice, was 18 American Journal of Speech-Language Pathology Vol. 6 No. 4 November 1997

3 completed on all patients (see Appendix). Abnormal gag reflex, abnormal volitional cough, dysarthria, and dysphonia were scored on a binary present/absent basis with specific characteristics of each parameter noted. Facial symmetry, muscle strength, range of motion, and coordination of speech and nonspeech movements were evaluated as part of routine clinical examination but were not included in analysis for prediction of dysphagia severity. Abnormal gag reflex was defined as no response or a weakened response of velum or pharyngeal wall constriction, unilaterally or bilaterally, on tactile stimulation of the posterior pharyngeal wall. Abnormal volitional cough was assessed by having the patient cough on command and was defined as a weak response, vocalized response, or no response. Assessment items to examine speech and voice, including repetition of single syllables and multisyllabic words, sustained phonation, and conversation, were similar to those described by Darley, Aronson, and Brown (1975). Dysphonia was defined as a disturbance in the parameters of vocal quality, pitch, or intensity and was classified as wet-hoarseness, strained, harsh, breathy, or nonspecific hoarseness. Dysarthria was defined as a speech disorder resulting from disturbances in muscular control affecting the areas of respiration, articulation, phonation, resonance, and/or prosody (Darley et al., 1975). Perceptual judgment was used to identify and characterize dysphonia and dysarthria. Clinical Swallowing Examination The clinical swallowing assessment consisted of ingestion of calibrated volumes of water. With the patient seated, the assessment was initiated with a 5-ml liquid bolus administered from a cup or straw, depending on the patient s preference, and progressed to 10 and 20 ml volumes. Laryngeal elevation was identified by palpation for each swallow; following each ingestion, the patient phonated ah to determine any change in vocal quality. All volumes were administered twice, for a total of 70 ml, unless the patient coughed or demonstrated alterations in vocal quality immediately after swallowing or within one minute, in which case the evaluation was terminated. Cough after swallow and voice change after swallow were scored on a binary present/absent basis. Fluoroscopic Examination The VSS was performed by Speech Pathology in conjunction with Radiology. VSS samples were recorded using a Super-VHS videocassette recorder that was coupled to a counter timer. The timer encoded digital time in hundredths of a second on each video frame. A video recording of the oral cavity (anterior to the lips) and the pharynx (inferior to the upper esophageal sphincter) was obtained in the lateral plane as the patient swallowed in duplicate liquid barium (81% wt/vol.) at volumes of 3, 5, 10, and 20 ml, and 1/2 teaspoon barium paste (100% wt/vol.). In addition, the patient masticated and swallowed half of a cookie and ingested unregulated amounts of thinned liquid barium. With the patient sitting, the examination was initiated with the 3-ml volume, administered from a cup or straw, and advanced accordingly unless the patient exhibited significant aspiration that could not be eliminated with therapeutic intervention, at which time the study was discontinued. Video recordings were analyzed using the slow motion and frame-by-frame capabilities of the recorder. Parameters rated during the VSS were initiation of oral movement, coordination of oral movement, anterior bolus loss, oral stasis, elicitation of the pharyngeal swallow, laryngeal elevation, pharyngeal stasis, penetration, and aspiration. Penetration was defined as entry of barium into the laryngeal vestibule superior to the true vocal folds; retention of penetrated material in the laryngeal vestibule was noted but not classified according to depth (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996). Aspiration was defined as entry of barium inferior to the level of the true vocal folds. Dysphagia severity was rated on a scale of 0 (normal), 1 (mild), 2 (moderate), 3 (moderate-severe), and 4 (severe). This rating system was designed to be easily derived from the VSS and to assess the frequency of aspiration as well as the viscosity of aspirated material in order to determine dysphagia severity. It was not intended to fully detail the characteristics of pentration and aspiration as delineated by Rosenbek et al. (1996). Normal swallowing (score 0) was defined as overall normal functioning of the oropharyngeal swallowing mechanism with no resultant penetration or aspiration. Mild dysphagia (score 1) was classified as oral and/or pharyngeal dysfunction resulting in no more than intermittent evidence of trace penetration into the laryngeal vestibule with immediate clearing. Moderate dysphagia (score 2) was classified as oral and/or pharyngeal dysfunction resulting in consistent laryngeal penetration with vestibule stasis and/or two or fewer instances of aspiration with a single consistency. Moderate-severe dysphagia (score 3) was classified as oral and/or pharyngeal dysfunction resulting in consistent aspiration of a single viscosity. Severe dysphagia (score 4) was identified as oral and/or pharyngeal dysfunction resulting in aspiration of more than one consistency. Severity was determined before therapeutic intervention was initiated. Videofluoroscopic swallow studies were rated by the second author, who was blind to results of the clinical examination. Statistical Analyses In this study, VSS classification of dysphagia severity was defined as the gold standard in establishing the presence or absence of dysphagia and served as the outcome variable. Data from the dysphagia severity rating scale, described earlier, were collapsed into two categories: mild dysphagia/normal swallowing (scores 0 1) and moderate to severe dysphagia (scores 2 4). The six parameters of the clinical examination were the predictor variables. In addition, the six predictor variables were combined into an index score, with a value of 1 if two or more variables were present and 0 if fewer than two were present. These data were analyzed comparing results of the clinical examination with results of the VSS. Sensitivity and specificity were calculated for each clinical feature as Daniels McAdam Brailey Foundas 19

4 TABLE 1. Distribution of clinical features according to dysphagia severity classification and risk of aspiration. Clinical Feature Dysphagia Severity N DYSP DYSR AVC AGR CAS VCAS No Risk of Normal (Score 0) Aspiration Mild (Score 1) Group Total 33 9 (27) 15 (45) 5 (15) 11 (33) 7 (21) 4 (12) Risk of Moderate (Score 2) Aspiration Moderate-Severe (Score 3) Severe (Score 4) Group Total (73) 22 (85) 11 (42) 14 (54) 17 (65) 7 (27) Percentages in parenthesis. N = number, DYSP = dysphonia, DYSR = dysarthria, AVC = abnormal volitional cough, AGR = abnormal gag reflex, CAS = cough after swallow, VCAS = voice change after swallow. an indicator of dysphagia severity. Sensitivity was operationally defined as the probability that a diagnostic sign (clinical feature) would be positive given that a disease (moderate to severe dysphagia) was truly present. Specificity was operationally defined as the probability that a diagnostic sign would not be positive given that a disease was not truly present. To obtain an initial estimate of the clinical significance of this procedure, a phi coefficient was calculated (Meline & Schmitt, 1997) to determine the effect size of the χ 2 obtained when discriminating between normal swallowing/mild dysphagia and moderate to severe dysphagia via the presence or absence of two or more clinical indicators. To assess interrater reliability of identification of dysphagia severity on VSS, all examinations were measured by the a second judge (the first author). Each recording was coded by number to assure that the reviewer was blind. The pattern of agreement for assignment of the same dysphagia severity score was 66% (r =.87) with all discrepancies within one severity score. Reliability for distinguishing normal swallowing/mild dysphagia (scores 0 1) from moderate to severe dysphagia (scores 2 4) was 92%. To measure intrarater reliability, one-third of the VSSs were remeasured in a blinded fashion by the original examiner (the second author). Assignment of the same dysphagia severity score was 80% (r =.93). Agreement in distinguishing normal swallowing/mild dysphagia (scores 0 1) from moderate to severe dysphagia (scores 2 4) was 95%. Results Forty-four of the 59 acute stroke patients (74.6%) presented with oropharyngeal dysphagia of varying severity. Three of the 59 patients (5.1%) were classified with severe dysphagia, 8 (13.6%) had moderate-severe dysphagia, 15 (25.4%) had moderate dysphagia, 18 (30.5%) had mild dysphagia, and 15 (25.4%) had normal swallowing as determined by VSS. Nineteen of the 26 patients with moderate to severe dysphagia demonstrated aspiration, with 13 of these patients aspirating silently during VSS. Of the total stroke sample, 47% presented with dysphonia, 63% presented with dysarthria, 27% presented with abnormal volitional cough, 42% presented with abnormal gag reflex, 41% presented with cough after swallow, and 19% presented with voice change after swallow. Table 1 summarizes the frequency distribution of the clinical features for dysphagia severity by group. Chisquare analyses revealed the following clinical features to be significantly predictive of dysphagia severity: dysphonia, dysarthria, abnormal volitional cough, and cough after swallow (p <.05). Voice change after swallow and abnormal gag reflex were not significant in isolation in predicting dysphagia severity. Refer to Table 2 for χ 2, sensitivity, and specificity data. Although abnormal gag reflex was initially treated as a dichotomous variable, further analysis was performed to determine if specific characteristics of this feature were associated with dysphagia severity. Of the 25 patients presenting with an abnormal gag reflex, 12 presented with bilateral absence of a gag reflex, 3 presented with unilateral absence, and 10 presented with weakened sensation. Of these three types, only bilaterally absent gag reflex was revealed to be significantly predictive of dysphagia severity (χ 2 = 5.85; p =.0156; sensitivity, 34.6; specificity, 90.9). The observance of two clinical features correctly distinguished 13 of 15 patients (87%) with normal swallowing, 8 of 18 patients (44%) with mild dysphagia, 14 of 15 patients (93%) with moderate dysphagia, 7 of 8 patients (88%) with moderate-severe dysphagia, and 3 of 3 patients (100%) with severe dysphagia. When collapsed according TABLE 2. Analyses of individual clinical features and two or more features in distinguishing dysphagia severity. Variable Sensitivity Specificity χ 2 p Dysphonia Dysarthria Abnormal Gag Reflex Abnormal Volitional Cough Cough After Swallow Voice Change After Swallow Two Clinical Features American Journal of Speech-Language Pathology Vol. 6 No. 4 November 1997

5 to risk of aspiration (scores 2 4) versus no risk of aspiration (scores 0 1), the observance of two clinical features correctly distinguished mild dysphagia/normal swallowing from moderate/severe dysphagia in 45 of 59 (76.2%) patients (χ 2 = 20.96; p <.00005; sensitivity, 92.3; specificity, 66.7) (Table 2). Of the 26 patients classified with at least a moderate dysphagia on VSS, observance of two or more clinical features accurately identified 24 patients (92.3%). A linear trend was not observed in that a progressive increase in dysphagia severity did not occur as the number of predictive variables increased. The phi coefficient equaled.596, which is typically associated with large effect size, as defined by Cohen (1988), and suggests that the described procedure is quite effective at discriminating between normal swallowing/mild dysphagia and moderate to severe dysphagia. Discussion In the current investigation, we used an objective clinical assessment, including an oropharyngeal examination and a water swallow test, to establish whether this clinical evaluation predicted dysphagia severity as confirmed by VSS in acute stroke patients. The results of this study demonstrate that this clinical assessment has utility in the evaluation of acute stroke patients with probable dysphagia who may be at risk for the development of aspiration. Moreover, it provides clinicians with empirical data on which to recommend VSS for acute stroke patients. The six clinical features that Daniels et al. (in press) identified as being indicative of increased risk of aspiration in acute stroke patients can be used to determine dysphagia severity and the need for a VSS in acute stroke patients. The presence of two or more of these six clinical features dysphonia, dysarthria, abnormal volitional cough, abnormal gag reflex, cough after swallow, and voice change after swallow provides an objective clinical indicator of stroke patients at risk for aspiration. Of those patients classified with at least a moderate dysphagia on VSS, the presence of two or more of these six clinical features correctly predicted dysphagia severity with 92% accuracy. The observed effect size was large, suggesting that the identification of any two of these six clinical features has clinical significance in distinguishing patients with normal swallowing/mild dysphagia from patients with moderate to severe dysphagia. Given that our patients with moderate to severe dysphagia are at greater risk of aspirating than patients with mild dysphagia, and given that the presence of two or more of these six clinical features accurately predicts which patients have moderate to severe dysphagia, it appears that this clinical screening method may provide objective criteria for determining which acute stroke patients require VSS for further evaluation of dysphagia. For patients with moderate to severe dysphagia and increased risk of aspiration, radiographic evaluation is essential to detail oral and pharyngeal swallowing integrity and to determine nutritional and therapeutic management. Although bedside dysphagia screenings may predict mortality outcome (Smithard et al., 1996), caution must be used when prescribing treatment and diet based solely on a clinical evaluation. We identified 13 patients with silent aspiration during ingestion of liquid barium during VSS, yet nine of these patients displayed a cough during the water swallow examination. As liquid barium has greater viscosity than water, one cannot assume that a thick liquid will eliminate aspiration. Therefore, it is suggested that VSS documentation may be critical in determining the value of increased liquid viscosity. However, this clinical assessment appears to be a valid screening tool for the identification of acute stroke patients at risk for aspiration. It also would expedite the proper management of appropriate patients, decrease unnecessary radiation exposure, and facilitate cost management by eliminating unnecessary radiographic procedures. In sum, it would help to identify patients at risk for aspiration early in their hospitalization. It is important to emphasize that this screening assessment is used to identify patients at risk for aspiration but does not predict patients at risk for developing pneumonia. With accurate clinical and radiographic diagnosis and appropriate treatment, the development of pneumonia secondary to prandial aspiration should be limited. In the current study, all patients identified with moderate to severe dysphagia were treated and, therefore, in our sample it is unknown how many patients would have developed aspiration pneumonia without intervention. A water swallow test is incorporated into the clinical screening examination developed for this study. Numerous previous studies have evaluated the effectiveness of water swallow testing; however, these studies have used small (5 10 ml) volumes (Barer, 1989; Kidd et al., 1993) that may not have identified deglutitive dysfunction. In contrast, the use of large ( ml) volumes (DePippo et al., 1992, 1994; Gordon et al., 1987; Nathadwarawala et al., 1994) may improve diagnostic accuracy in identifying swallowing dysfunction; however, the use of large volumes of water may increase the risk of aspiration of large, uncontrolled amounts of water and may result in medical complications. The strength of the clinical water swallowing examination described in this paper is that it gradually progresses from smaller to larger volumes of ingestion according to patient performance. Testing is discontinued on evidence of a cough or voice change within one minute of swallowing. In addition, this clinical dysphagia assessment does not rely solely on response to ingestion of water, which will not identify patients who silently aspirate (Logemann, 1983; Splaingard et al., 1988). This assessment also evaluates clinical features such as voice, speech, volitional cough, and gag reflex. Observance of abnormalities within these parameters, as detailed earlier, may facilitate the identification of patients who demonstrate silent aspiration on the clinical swallowing evaluation. It is of note that abnormal gag reflex and voice change after swallow were not significantly predictive when considered as independent predictors of dysphagia severity. This result differs from our previous study in which abnormal gag reflex and voice change after swallow were associated with increased risk of aspiration in acute stroke patients (Daniels et al., in press). This may be explained in part by the examination of two different Daniels McAdam Brailey Foundas 21

6 variables: aspiration and dysphagia severity. Although these two outcome measures are closely related, they are not identical and some discrepancy is to be expected when employing a similar set of predictor variables to identify both outcome measures. Despite these differences, a moderate positive finding was evident for the variables in question. Moreover, further analyses of the gag reflex revealed that the prediction of dysphagia severity was significant with identification of bilateral absence of a gag reflex versus identifying any abnormality in the gag reflex. Although our results differ from those reported by Leder (1997), who noted no relationship between the gag reflex and aspiration, Leder did not report medical diagnosis. Although the gag reflex does decrease with age (Davies, Kidd, Stone, & MacMahon, 1995), stroke may also affect glossopharyngeal afferent integrity, and the interaction of this clinical parameter with the other clinical predictors appears to be sensitive in predicting risk of aspiration. Further study is warranted in the delineation of the role of the gag reflex in association with dysphagia severity, particularly when pairing an abnormal gag reflex with other predictors. Identification of two of these six clinical features to distinguish normal swallowing/mild dysphagia from moderate to severe dysphagia provided the best balance between the sensitivity and specificity. The overall high specificity rates, primarily noted with abnormal volitional cough and voice change after swallow, were achieved by sacrificing sensitivity. Identification of two of more of the six clinical features avoided the false inflation of specificity or sensitivity. False-positive results were noted with mild dysphagia in that 10 of the 18 patients with mild dysphagia presented with two or more of the six clinical features of aspiration, even though swallowing integrity was primarily intact and there was no risk of aspiration. However, analysis of the presence of three features to predict dysphagia severity only decreased the false-positive count by three and, moreover, increased the false-negative count by three. As patients with moderate to severe dysphagia are at greater risk of aspiration and resulting complications, a low falsenegative index was deemed more suitable as 92% of the patients with moderate to severe dysphagia were identified using two clinical features. Limitations with the study include time delays between the clinical evaluations and the VSS and the limited reliability data. Although same-day clinical and radiographic assessments would be optimal, the time delay we encountered between the clinical evaluations and the VSS may be more consistent with typical hospital scheduling. Therefore, ecological validity would be high in that these results represent real-time constraints of practicing swallowing clinicians. Furthermore, by having a time delay between the clinical evaluation and the VSS, errors would be in the conservative direction, which may further support the strength of our clinical features. Exact values for reliability are unknown for the oropharyngeal and water swallow assessments. However, given that a valid relationship was established between our procedure and classification of dysphagia severity, one may assume at least modest levels of test-retest reliability (Sechrest, 1984). Further research conducted to explore the possibility of a more reliable method for discrimination between patients at risk of aspiration should enhance the results of our study. Nevertheless, before we recommend widespread use of this screening tool, these findings need to be replicated with a new sample to ensure stability of the data. This simple yet valid screening for dysphagia in acute stroke patients can easily be used by speech-language pathologists. Given that aspiration and the ensuing complications can increase length of hospitalization and delay initiation of rehabilitation, it is imperative that patients with a risk of aspiration be identified within the first days of admission so that proper management, such as diet alteration and compensatory strategies, can be implemented expediently. In addition, swallowing treatment based on physiological data obtained from the VSS can be initiated in patients that warrant this intervention. A clinical decision-making flowchart (Figure 1) for dysphagia management in the acute stroke population has been instituted at the Veterans Affairs Medical Center in New FIGURE 1. A clinical decision-making flowchart for dysphagia management. 22 American Journal of Speech-Language Pathology Vol. 6 No. 4 November 1997

7 Orleans. With early identification and intervention, the development of aspiration pneumonia can be reduced in acute stroke patients, consequently, decreasing length of hospitalization and expediting rehabilitation efforts. Future studies should focus on the employment of the dysphagia clinical pathway to further support the validity of this dysphagia clinical evaluation. Author Note The authors gratefully acknowledge the Research Service of VAMC, New Orleans, and the constructive comments of Donald A. Robin and Thomas W. Powell. References Aviv, J. E., Martin, J. H., Sacco, R. L., Zager, D., Diamond, B., Keen, M. S., & Blitzer, A. (1996). Supraglottic and pharyngeal sensory abnormalities in stroke patients with dysphagia. Annals of Otology, Rhinology, and Laryngology, 105, Barer, D. H. (1989). The natural history and functional consequences of dysphagia after hemispheric stroke. Journal of Neurology, Neurosurgery, & Psychiatry, 52, Cohen, J. (1988). 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Swallow management in patients on an acute stroke pathway: Quality is cost effective. Archives of Physical Medicine and Rehabilitation, 76, Ott, D. J., Hodge, R. G., Pikna, L. A., Chen, M. Y. M., & Gelfand, D. W. (1996). Modified barium swallow: Clinical and radiographic correlation and relation to feeding recommendations. Dysphagia, 11, Rosenbek, J. C., Robbins, J., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, Schmidt, D., Holas, M. A., Halvorson, K. A., & Reding, M. J. (1994). Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia, 9, Sechrest, L. (1984). Reliability and validity. In A. S. Bellack & M. Hersen (Eds.), Research methods in clinical psychology (pp ). New York: Pergamon. Smithard, D. G., O Neill, P. A., Park, C., Morris, J., Wyatt, R., England, R., & Martin, D. F. (1996). Complications and outcomes after acute stroke: Does dysphagia matter? Stroke, 27, Splaingard, M., Hutchins, B., Sulton, L., & Chaudhuri, G. (1988). Aspiration in rehabilitation patients: Videofluoroscopic vs. bedside clinical assessment. Archives of Physical Medicine and Rehabilitation, 69, Received July 7, 1997 Accepted September 4, 1997 Contact author: Stephanie K. Daniels, MS, Speech Pathology, Department of Veteran Affairs Medical Center, 1601 Perdido Street, New Orleans, LA daniels.stephanie_k@new-orleans.med.va.gov Key Words: stroke, dysphagia, aspiration, clinical swallowing assessment, videofluoroscopic swallow study Daniels McAdam Brailey Foundas 23

8 Appendix Oral Pharyngeal and Clinical Swallowing Examination Mandible (CN V) Symmetry on Extension Strength Lips (CN VII) Symmetry: Rest Retraction Protrusion Strength Nonspeech Coordination: Repetitive Movement Alternating Movement Speech Coordination: Repetitive (/p, w/) Alternating (/p-w/) Tongue (CN XII) Symmetry: Rest Protrusion Lateralization Elevation Yes/No Lateralization Yes/No Fasciculations Yes/No Strength Nonspeech Coordination: Repetitive Movement Alternating Movement Speech Coordination: Repetitive (/t, k/) Alternating (/t-k/) Alternating Movement (/p^t^k^/) Multisyllabic Word Repetition (tip top, baseball player, several, caterpillar, emphasize) Conversation: (speech, voice, coordination characteristics) Laryngeal Function: Isolated Movement (/i-i-i/ on one breath) Alternating Movement (/u-i/) Buccofacial Apraxia: Blow out a candle Lick an ice cream cone Lick milk off your top lip Sip through a straw Kiss a baby Velum (CN IX, X, XI) Symmetry: Rest Elevation Coordination: Repetitive Movement (/a/) Appearance of Hard Palate Dentition Reflexes (CN IX, X, XI) Gag (Abnormal: Yes/No) Swallow (Cough: Yes/No) (Voice Change: Yes/No) Additional Information c/o Facial Numbness or Tingling: Yes/No Light Touch Dysphonia: Yes/No (mild, moderate, severe) Dysarthria: Yes/No (mild, moderate, severe) Breath Support Resonance Volitional Cough (Abnormal: Yes/No) 24 American Journal of Speech-Language Pathology Vol. 6 No. 4 November 1997

9 Clinical Assessment of Swallowing and Prediction of Dysphagia Severity Stephanie K. Daniels, Colleen P. McAdam, Kevin Brailey, and Anne L. Foundas Am J Speech Lang Pathol 1997;6;17-24 This article has been cited by 6 HighWire-hosted article(s) which you can access for free at: This information is current as of November 29, 2010 This article, along with updated information and services, is located on the World Wide Web at: