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The Dysphagia Outcome and Severity Scale


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The Dysphagia Outcome and Severity Scale (DOSS) is a simple, easy-to-use, 7-point scale developed to systematically rate the functional severity of dysphagia based on objective assessment and make recommendations for diet level, independence level, and type of nutrition. Intra- and interjudge reliabilities of the DOSS was established by four clinicians on 135 consecutive patients who underwent a modified barium swallow procedure at a large teaching hospital. Patients were assigned a severity level, independence level, and nutritional level based on three areas most associated with final recommendations: oral stage bolus transfer, pharyngeal stage retention, and airway protection. Results indicate high interrater (90%) and intrarater (93%) agreement with this scale. Implications are suggested for use of the DOSS in documenting functional outcomes of swallowing and diet status based on objective assessment.
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The Dysphagia Outcome and Severity Scale
Karen H. O’Neil, MA, Mary Purdy, PhD, Janice Falk, MA, and Lanelle Gallo, MS
Hartford Hospital, Hartford, Connecticut, USA
Abstract. The Dysphagia Outcome and Severity Scale
(DOSS) is a simple, easy-to-use, 7-point scale developed
to systematically rate the functional severity of dyspha-
gia based on objective assessment and make recommen-
dations for diet level, independence level, and type of
nutrition. Intra- and interjudge reliabilities of the DOSS
was established by four clinicians on 135 consecutive
patients who underwent a modified barium swallow pro-
cedure at a large teaching hospital. Patients were as-
signed a severity level, independence level, and nutri-
tional level based on three areas most associated with
final recommendations: oral stage bolus transfer, pharyn-
geal stage retention, and airway protection. Results indi-
cate high interrater (90%) and intrarater (93%) agree-
ment with this scale. Implications are suggested for use
of the DOSS in documenting functional outcomes of
swallowing and diet status based on objective assess-
Key words: Dysphagia Severity Scales Out-
come — Videofluoroscopy — Reliability Deglutition
Deglutition disorders.
The demand for outcome data in dysphagia research has
elevated in recent years with the expanding presence of
managed care, and the rapidly changing Medicare envi-
ronment. Clinicians are challenged by third-party payers
and physicians to prove the validity and reliability of
dysphagia assessments from which treatment recommen-
dations are made. However, the consistency of documen-
tation in evaluating dysphagia has not been encourag-
ingly high in the dysphagia literature to date. Wilcox et
al. [1] studied interjudge agreement of speech patholo-
gists on observation of swallow deficits on videofluoro-
scopic examination and agreement of treatment recom-
mendations. They stated that “instances of high agree-
ment among clinicians were not abundant” [1]. Ekberg et
al. studied interrater reliability of radiologists on cinera-
diographic assessments and found that “interobserver
variability in cineradiographic assessment of pharyngeal
function seems to be a major function of observer expe-
rience” [2]. There is also significant demand to deter-
mine the efficacy, effectiveness, and cost benefit of swal-
lowing therapy for large patient populations and within
individual treatment facilities. Currently, there is a pau-
city of research to assuage these demands, and clinicians
have few means of reliably documenting such functional
Other areas in rehabilitation outcomes have been
systematically and internationally studied with the func-
tional independence measure (FIM) [3]. The FIM is “one
of the most widely used methods of assessing basic qual-
ity of daily living in persons with disability” [4]. The
FIM is a 7-point scale across 18 motor and cognitive/
social areas which allows a patient’s progress to be
charted reliably “across a variety of settings, raters and
patients,” as reviewed by Ottenbacher et al., with an
interrater reliability of 89–99% [4]. Dysphagia is not
currently an area on the FIM, but it is a common dis-
ability of stroke patients in rehabilitation settings and of
nursing home residents. The occurrence of dysphagia
following stroke has been estimated at approximately
25–45% [5–9]. Moreover, the incidence of dysphagia in
nursing homes has been reported by Donner (1986) as
40% of the population [10]. To address the quality and
efficacy of care in these patients across clinicians and
settings, a reliable and uniform measure of dysphagia
severity is necessary.
Currently there are scales available that clinicians
can use to subjectively qualify the level of dysphagia in
adult populations. However, reliability of these measures
is unknown and there are no correlates to objective per-
Correspondence to: Karen H. O’Neil, M.A., Speech Pathology, Hart-
ford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
Dysphagia 14:139–145 (1999)
© Springer-Verlag New York Inc. 1999
formance. Cherney et al. described seven functional se-
verity levels of dysphagia based on independence and
nutritional level in the RIC Clinical Evaluation of Dys-
phagia (CED) manual [11]. ASHA is currently field test-
ing the ASHA Functional Communication Measure swal-
lowing subscale for reliability [12]. This 7-point scale
also rates severity based on the patient’s ability to meet
nutritional needs and independence with compensatory
strategies. These scales do not attempt to relate severity
to objective measures; thus, it is difficult to establish
consistency in the documentation of patient care or cred-
ibly claim significant changes in a patient’s condition.
A few investigators have developed scales that
relate dysphagia presentation on videofluoroscopic as-
sessment to severity and have then tested agreement;
however, they failed to incorporate functional levels of
independence, diet, and nutrition, and reliability of these
scales has not been especially high. Rosenbek et al. de-
veloped the Penetration–Aspiration Scale to describe
penetration and aspiration events and found the interrater
reliability to be 57–75% between judge pairs and overall
intrajudge reliability to be 74% for agreement of the
same judge regrading 75 swallows [13]. Ott et al. de-
scribed four levels of severity (0–3) for a bedside swal-
lowing assessment and modified barium swallow
(MBS): (a) mild dysphagia “if bolus control and trans-
port were delayed or if mild stasis occurred without la-
ryngeal penetration,” (b) moderate dysphagia “included
poor oral transport, pharyngeal stasis with all consisten-
cies, laryngeal penetration or mild aspiration with only
one consistency,” and (c) severe dysphagia was present
when “substantial aspiration occurred” or if the patient
failed to swallow [14]. They then determined agreement
between the bedside and MBS severity ratings as 59%
but did not present inter- or intrajudge reliabilities of the
ratings or the videofluoroscopic examinations.
Daniels et al. developed a five-level severity
scale based on the MBS procedure: 0 (normal), 1 (mild)
with “no more than intermittent evidence of trace pen-
etration into the laryngeal vestibule with immediate
clearing,” 2 (moderate) as “consistent laryngeal penetra-
tion with vestibule stasis and/or 2 or fewer instances of
aspiration with a single consistency,” 3 (moderate–
severe) as “consistent aspiration of a single viscosity,”
and 4 (severe) as “aspiration of more than one consis-
tency” [15]. The interrater reliability of this scale was
found to be 66%, and the intrarater reliability was 80%.
The purpose of this study was to develop an eas-
ily administered, seven-level functional scale that as-
signed severity with acceptable reliability based on re-
sults of the MBS procedure and allowed improved con-
sistency in recommendations for nutrition level, diet, and
Scale Development
A retrospective and informal analysis of all MBS reports
from a single month showed significant variability across
and within clinicians on what was documented as mild,
moderate, or severe dysphagia. There was also notable
inconsistency in the recommendations for supervision,
diet consistency, and nutritional level based on the docu-
mented MBS findings. The Dysphagia Outcome and Se-
verity Scale (DOSS) was developed by four clinicians in
a large teaching hospital for the purpose of establishing
a consistent method of documentation and improved
quality of care in patients objectively diagnosed with
The first stage of development of the DOSS in-
corporated three factors previously identified in the lit-
erature that allow for comparison among a wide range of
patients and changes within a single patient over time.
1. Level of independence. The scale was divided into
seven independence levels based on the FIM model
and linked to severity. The initial levels were 7 within
normal limits, 6 (modified independence), 5 (distant
supervision), 4 (intermittent supervision), 3 (total su-
pervision), 2 (maximum assistance), and 1 (depen-
dent/non-per-oral nutrition [NPO]).
2. Level of nutrition. The scale was then divided into the
two possible recommendations for nutrition and were
linked to severity level: levels 7–3 (full oral nutrition)
and levels 2–1 (nonoral nutrition).
3. Diet level and diet modifications. Guidelines for diet
modifications were then added for each severity level
that allowed oral intake: levels 7–6 (normal diet con-
sistency), level 5 (may need one diet consistency re-
striction), level 4 (one to two diet consistency restric-
tions), and level 3 (two or more diet consistency re-
The next stage of development focused on objec-
tively defining the characteristics of the impaired swal-
low and determining how the dysphagia would impact
the patient’s level of independence, nutrition, and diet
recommendations. A careful review of 100 previous
MBS studies was conducted to determine which factors
dictated nutritional status. Of the 100 reports reviewed,
15% were NPO, 65% had recommendations for a modi-
fied diet, and 20% were allowed a normal diet as dictated
by the factors of oral stage transfer, pharyngeal stage
retention, and/or airway penetration/aspiration.
Oral Stage Transfer
Logemann summarized the oral stage as involving “in-
tact labial musculature to prevent material from leaking
140 K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale
from the oral cavity, intact lingual movement to propel
the bolus posteriorly, and intact buccal musculature to
insure that material does not fall into the lateral sulci”
[16]. Patients in the present study were clinically judged
on the degree of bolus loss or oral retention (after the
swallow) and the patient’s ability to compensate with or
without cueing. For example, if a patient is unable to
move a bolus posteriorly into the oral cavity or loses the
entire bolus due to poor labial closure, that patient will
have difficulty meeting nutritional needs and would be
considered more severe. However, if that patient is able
to use strategies, verbal cues, or positions to compensate
for that deficit and transfer the bolus through the oral
cavity effectively, that would be considered less severe
but with different levels of assistance needed.
Pharyngeal Stage Retention
Pharyngeal retention is defined as material that remains
in the pharynx (valleculae and/or pyriform sinuses) after
a swallow has been completed. As stated by Cherney et
al., “residue may remain in the valleculae and/or pyri-
form sinuses; if particles fall into the airway, aspiration
may occur after the swallow reflex” [11]. The impact of
retention on severity of dysphagia was based on the rela-
tive amount of barium retained in the valleculae and/or
pyriform sinuses (mild, moderate, or severe). Further-
more, it considers the patient’s ability to either clear the
retention automatically with a re-swallow or clear re-
tained material with a re-swallow when cued (told to
re-swallow). For example, if a patient swallows a bolus
but a significant amount is left in pharynx after the swal-
low and no attempts to clear the material is made even
with cues, the patient’s ability to maintain nutrition
safely is considered severely impaired. However, if that
same patient is able to clear the retention spontaneously
or with cued re-swallows or compensatory strategies, the
impact of that retention is considered less severe.
Airway penetration is defined as material that enters the
airway into the laryngeal vestibule, above or to the level
of the vocal cords. Aspiration is defined as material that
goes into the trachea, below the level of the vocal cords.
These terms were defined in a similar way by Rosenbek
et al. [13]. The following factors were considered in
determining diet recommendations: the number of con-
sistencies penetrated or aspirated, the presence or ab-
sence of a reflexive and/or elicited cough to clear pen-
etration or aspiration, and the level to which the material
penetrated into the airway. If a patient aspirated on all
consistencies and did not or could not cough to clear the
aspirated material, this was considered very severe and
would impact that patient’s ability to tolerate any con-
sistency effectively. If that same patient was able to use
a strategy to eliminate aspiration with at least one con-
sistency, oral intake might be possible with assistance.
The impact of that aspiration on nutrition, diet, and in-
dependence would be considered less severe. The sever-
ity of penetration–aspiration was based on retrospective
report analysis and through the general framework pro-
posed by Rosenbek et al. in their study on the penetra-
tion–aspiration scale [13].
Once the scale was fully outlined incorporating
all these factors, it was piloted for approximately 1
month, with ongoing changes made until the final revi-
sion was completed (Table 1).
Subjects and Methods
The results of 135 consecutive patients in a 3-month period to undergo
an MBS procedure at Hartford Hospital, representing a wide range of
acuity and diagnoses (Table 2), were examined. Neurological diag-
noses included stroke, neurosurgery, Parkinson’s disease, dementia,
encephalopathy and traumatic brain injury, muscular dystrophy, etc.
General medical/surgical diagnoses included gastrointestinal disorders
(gastrointestinal bleed, esophagi, small bowel obstruction, etc.), HIV,
sepsis, renal and urological disorders, diabetes, dehydration, malnutri-
tion, all general surgery (with the exception of cardiac and neurologi-
cal), etc. Pulmonary patients included persons with pneumonia, chronic
obstructive pulmonary disease, asthma, respiratory failure, pleural ef-
fusions, etc. Cardiac patients included patients who had a myocardial
infarction, open heart surgery, congestive heart failure, coronary artery
disease, carotid endarterectomy, heart transplant, etc. (without neuro-
logical event). Ear, nose, and throat (ENT) diagnoses included laryn-
geal cancer, vocal cord paralysis, and polyps. Other diagnoses were
The subject group included 57 women and 78 men and was a
sample of acute care patients, outpatients, and acute rehabilitation pa-
tients. The patients’ ages ranged from 21 to 95 years, with a mean age
of 73 years. The DOSS was used to assign a severity level once the
objective assessment had been determined by the speech pathologist
and the radiologist. The videofluoroscopic swallowing assessments fol-
lowed hospital protocol adapted from Logemann’s procedures [7]. A
full medical history was obtained prior to examination, and an oral–
motor/voice examination was completed. Patients were given barium in
thin, medium, thick, puree, and solid consistencies as per their ability
to swallow. Review of the videotape was completed and documented
on a report form according to department protocol (Table 3).
Once the report was completed and severity assigned, a copy
was made of the contents (Table 3) for each patient. This copy was
randomly given to one of the three other trained speech pathologists
who then blindly assigned severity level based on the DOSS. The report
was then given back to the original clinician for intrajudge rating after
a period of 2–4 weeks, and a severity level was blindly assigned based
on the contents presented in Table 3.
All participating speech pathologists underwent training
in using the DOSS. Specific instruction in the guidelines
for use included careful attention to severity level head-
K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale 141
ings and discriminating factors to consider when decid-
ing between levels (patient’s environment, premorbid
nutrition, cognition, acuity of dysphagia, current medical
status). These factors are integral to a careful decision-
making process for level of nutrition, diet, and indepen-
dence and were assessed by chart review, history intake
with the patient, and clinical bedside evaluation.
The patient’s environment is defined as the
amount of supervision that is realistically available for
that patient. For example, the speech pathologist can bet-
ter decide between level 2 (nonoral intake) and level 3
(oral intake with total assistance for strategies) when
accurate and realistic consideration of possible supervi-
sion is known. Premorbid nutrition is also very pertinent
to making difficult decisions between recommending full
oral intake versus nonoral intake. A patient’s ability to
Table 1. Dysphagia outcome and severity scale—final revision
Full per-oral nutrition (P.O): Normal diet
Level 7: Normal in all situations
Normal diet
No strategies or extra time needed
Level 6: Within functional limits/modified independence
Normal diet, functional swallow
Patient may have mild oral or pharyngeal delay, retention or trace epiglottal undercoating but independently and spontaneously
May need extra time for meal
Have no aspiration or penetration across consistencies
Full P.O: Modified diet and/or independence
Level 5: Mild dysphagia: Distant supervision, may need one diet consistency restricted
May exhibit one or more of the following
Aspiration of thin liquids only but with strong reflexive cough to clear completely
Airway penetration midway to cords with one or more consistency or to cords with one consistency but clears spontaneously
Retention in pharynx that is cleared spontaneously
Mild oral dysphagia with reduced mastication and/or oral retention that is cleared spontaneously
Level 4: Mild–moderate dysphagia: Intermittent supervision/cueing, one or two consistencies restricted
May exhibit one or more of the following
Retention in pharynx cleared with cue
Retention in the oral cavity that is cleared with cue
Aspiration with one consistency, with weak or no reflexive cough
Or airway penetration to the level of the vocal cords with cough with two consistencies
Or airway penetration to the level of the vocal cords without cought with one consistency
Level 3: Moderate dysphagia: Total assist, supervision, or strategies, two or more diet consistencies restricted
May exhibit one or more of the following
Moderate retention in pharynx, cleared with cue
Moderate retention in oral cavity, cleared with cue
Airway penetration to the level of the vocal cords without cough with two or more consistencies
Or aspiration with two consistencies, with weak or no reflexive cough
Or aspiration with one consistency, no cough and airway penetration to cords with one, no cough
Nonoral nutrition necessary
Level 2: Moderately severe dysphagia: Maximum assistance or use of strategies with partial P.O. only (tolerates at least one consistency safely
with total use of strategies)
May exhibit one or more of the following
Severe retention in pharynx, unable to clear or needs multiple cues
Severe oral stage bolus loss or retention, unable to clear or needs multiple cues
Aspiration with two or more consistencies, no reflexive cough, weak volitional cough
Or aspiration with one or more consistency, no cough and airway penetration to cords with one or more consistency, no cough
Level 1: Severe dysphagia: NPO: Unable to tolerate any P.O. safely
May exhibit one or more of the following
Severe retention in pharynx, unable to clear
Severe oral stage bolus loss or retention, unable to clear
Silent aspiration with two or more consistencies, nonfunctional volitional cough
Or unable to achieve swallow
142 K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale
maintain oral nutrition before dysphagia will only be-
come more problematic with the onset of difficulty in
swallowing. Cognition also is important to consider
when deciding whether a patient will quickly and spon-
taneously learn strategies (level 6) or need supervision
due to poor memory (level 5 or below). Acuity of dys-
phagia refers to how acute the swallowing problem is to
the patient, and current medical status refers to the rela-
tive acuity of the overall medical issues. These factors
are critical in considering the risks that are considered
with a given patient and may guide a clinician toward a
more conservative stance on a patient with multiple cur-
rent medical concerns.
Following verbal instruction in the guidelines for
use of the DOSS, a peer review of videotaped MBS
studies with joint scorings was conducted. All discrep-
ancies in scoring were discussed and resolved.
Results are presented in Tables 4 and 5 and outline the
different types of reliability established (interjudge or
Table 2. Patient diagnoses
Diagnosis Neurological General medical/surgical Pulmonary Cardiac ENT Other
n (%) 81 (60) 32 (24) 10 (7) 8 (6) 3 (2) 1 (1)
Table 3. Report format
Medical summary: Current diet:
Mental status: Alert—Lethargic—Oriented—Confused—Cooperative—Uncooperative—Follows commands/spontaneously with cues—
Does not follow commands
Oral–motor Intact Impaired Nonfunctional Phase
Swallow reflex Oral
Volitional cough Leakage L/R lip
Reflexive cough Poor bolus formation
Lip closure Poor bolus propulsion
Lateral tongue Retention L/R sulcus
Anterior tongue Poor velopharyngeal closure
Posterior tongue Pharyngeal
Mandible Delayed pharyngeal swallow
Voice Reduced laryngeal elevation
Dentition/dentures Reduced epiglottal tilt
Reduced pharyngeal peristalsis
Cricopharyngeal dysfunction
Retention valleculae
Spontaneously cleared
Cleared with cue
Unable to clear
Retention pyriform
Spontaneously cleared
Cleared with cue
Unable to clear
Aiway penetration
Midway to cords
To cords, spontaneous cough
To cords, no cough
Eliminated with compensatory strategy
Productive spontaneous cough
Nonproductive cough
No cough (silent)
Eliminated with compensatory strategy
K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale 143
between two judges and intrajudge or between two grad-
ings by a single judge). Table 6 shows the number of
patients for each severity level and the reliability figures
for each severity level.
Of the 135 consecutive patients who underwent
an MBS procedure, 10 (7%) were rated as severe and 17
(12.6%) were rated as moderately severe by the initial
rater; all required nonoral nutrition according to recom-
mendations. Twenty-one (15.6%) of the 135 patients had
moderate dysphagia, 30 (22%) were rated as mild to
moderate, and 28 (21%) were considered to have mild
dysphagia; recommendations for these three groups al-
lowed full oral nutrition but with a restricted diet and
level of independence. A functional swallow was deter-
mined in 22 (16%) of the 135 patients, and seven (5%)
were rated as normal; both groups were allowed a normal
diet based on recommendations from the DOSS. (Ta-
ble 6).
On overall interrater reliability, both judges
agreed and assigned an exact match for 121 of 135 cases
(90%). The four judges constituted three judge pairs, and
the individual agreement between the two judges in each
pair is outlined in Table 4. The scores that disagreed
were off by one level on the scale in 13 of 14 instances
of error, and all were within two severity levels. As cited
in Table 6, interjudge agreement was good for rating all
levels of the scale (82–100%), with the highest concor-
dance on level 7/normal (100%), level 4/mild–moderate
(93%), level 6/within functional limits (91%), and level
1/severe (90%).
Total intrajudge reliability was 93% (125 of 135)
when the four judges reassigned the same severity level
on the second grading. Table 5 summarizes the pattern of
agreement for each individual judge. Reliability was
good across all levels of the scale (86–100%). The sec-
ond ratings that did not agree were off by only one se-
verity level in six of nine cases, and all disagreements
were within two severity levels (Table 5).
The purpose of the present study was to develop a scale
to rate the severity of dysphagia and functional level
based on objective measures from the MBS procedure
and to determine the reliability of the scale for an ac-
ceptable number of subjects. The scale was not intended
to determine reliability of the MBS procedure itself. It
was intended, however, to improve the consistency of
documentation and recommendations across clinicians
and within individual clinicians, provide a basis for com-
paring patients with each other and over time, and to
introduce a possible measure of functional outcomes in
dysphagia. The present results indicate that the DOSS
can be used by trained clinicians to better describe se-
verity level of dysphagia with excellent reliability and to
make more consistent recommendations for nutrition,
diet, and independence.
Scale development and use are founded on strong
documentation of MBS results on a detailed report for-
mat and training with discriminating factors critical to
appropriate recommendations. These factors include the
patients’ premorbid nutrition level, acuity of dysphagia,
current medical status, environment, and cognition. Use
of this scale may improve and highlight clinical attention
to important subtleties of assigning diagnosis and could
also improve communication between clinicians and al-
low a smoother continuum of care for dysphagic patients
across settings. This improved consistency of documen-
tation and recommendations would serve this area of our
profession well in a time that demands larger scale stud-
ies of efficacy, efficiency, and outcome.
However, the scale does not thoroughly define
each parameter (i.e., what constitutes “mild retention”)
and therefore requires subjective clinical determination
usually based on clinical experience. A clearer definition
of what determines such parameters as “severe aspira-
tion” or “severe retention” is also needed from future
studies. Also, the present study assessed reliability by
review of written report; therefore, reliability of the ac-
tual interpretation of the videotape and subsequent docu-
mentation was not determined. Further research is nec-
essary to determine the reliability of clinician’s interpre-
tation and documentation of MBS results using more
standardized report formats such as the one used in the
present study.
The DOSS may be an excellent and thorough
alternative to currently available scales to describe
functional dysphagia severity. Existing scales have re-
lied on too general and subjective descriptions per level,
have failed to encompass all important dysphagia issues,
or have not presented acceptable levels of reliability.
Both the Cherney et al. scale [11] and the ASHA scale
[12] are 7-point severity scales that assign severity based
on nutritional and independence levels but do not
associate each level with patients’ dysphagia deficits
Table 4. Interjudge reliability by judge pair
1–2 1–3 1–4 Total
Total rated 43 57 35 135
No. ratings agree 37 52 32 121
Reliability % 86 91 91 90
Scores that differed
by 1 (%) 6/6 (100) 5/5 (100) 2/3 (66) 13 (93)
Scores that differed
by 2 (%) 0 0 1/3 (33) 1 (7)
144 K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale
that can be objectively and consistently measured. The
aspiration–penetration scale by Rosenbek et al. [13]
provides excellent delineation of severity of airway
penetration. However, interrater reliability was only
fair (57–75%), and it did not allow for overall function-
al severity of dysphagia as a whole or address regularity
of diet, nutrition, or independence recommendations.
Similarly, the scale by Daniels et al. [15] specifies the
severity level in terms of penetration–aspiration with fair
reliability (66%). However, it neglects other key compo-
nents of both objective severity (retention, oral stage
deficits) and functional parameters (independence, nutri-
tion, diet).
This study has succeeded in presenting a more
functionally holistic and objective DOSS that addresses
all these areas. The DOSS can be used within 5 min by
trained clinicians to determine severity of dysphagia
based on objective measures. In addition, the DOSS was
proven to have excellent interrater (90%) and intrarater
(93%) reliabilities congruent with that of the internation-
ally recognized FIM [3]. Given the high reliability of the
DOSS, this tool could be valuable in objectively mea-
suring the natural history and outcome of dysphagia
across populations and in measuring efficacy of treat-
ment. Further studies are still needed with larger groups
of patients and longitudinally following patients across
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3. Guide for the Uniform Data Set for Medical Rehabilitation
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Table 5. Intrajudge reliability by judge
1 2 3 4 Total (all judges)
Total rated 73 20 27 15 135
No. ratings agree 71 17 24 13 125
Reliability % 97 85 89 87 93
Scores that differed by 1 (%) 1/2 (50) 2/3 (66) 3/3 (100) 0 6 (60)
Scores that differed by two (%) 1/2 (50) 1/3 (33) 0 2/2 (100) 4 (40)
Table 6. Number of patients and reliability by severity level
1 234567
n 10 17 21 30 28 22 7
Interjudge reliability % 90 82 90 93 86 91 100
Intrajudge reliability % 100 88 90 97 93 86 100
K.H. O’Neil et al.: Dysphagia Outcome and Severity Scale 145
... Dysphagia severity scales are instruments that aim to provide an assessment of patients and are useful both for individualising the approach and for evaluating the efficacy of the rehabilitative treatment. Among the most commonly used are the Dysphagia Outcome and Severity Scale (DOSS), 5 the Food Intake Level Scale (FIS) 6 and the Functional Oral Intake Scale (FOIS), 7 all designed for the adult population. ...
Introduction Oropharyngeal dysphagia (DOF) without proper evaluation can be underdiagnosed in certain groups of the pediatricpopulation. Meeting the needs of these patients can lead to an overload of their caregivers. Objectives To describe the epidemiological and clinical characteristics of the patients evaluated after starting a monographic DOF clinic (C-DOF) and study whether there are changes at the nutritional level, as well as the burden and impact that caregivers find on quality of life related to health (HRQL). Material and methods Descriptive observational study of patients evaluated in a C-DOF from its start-up. To evaluate HRQoL, an ad hoc survey adapted from the Swallowing Quality of Life Questionnaire of the adult population was designed. Results 103 patients were evaluated, 85.4% presenting some neurological disease. A videofluoroscopic study was performed in 51 patients (49.5%), reporting combined alterations in both the oral and pharyngeal phases in 64.7% of them. There was a directly proportional correlation between the severity of the DOF and the presence of aspirations, as well as with the patient's motor impairment. Regarding the anthropometric evaluation, there was a trend towards improvement in weight z-score (+0.14 SD), height (+0.17 SD) and BMI (+0.16 SD). Out of 46.2% of the caregivers reported that the DOF problem interfered negatively in the basic activities of daily life. The increase in HRQOL, after the evaluation in the monographic DOF clinic, was statistically significant overall. Conclusions The monographic DOF clinic provided specialized care, impacting positively at the nutritional status of patients, as well as perceived changes in HRQOL, with a probable impact on caregivers.
... Many kinds of swallowing function rating scales are used in clinics, such as the dysphagia outcome and severity scale, modified Mann assessment of swallowing ability, functional oral intake scale, functional dysphagia scale, and Kubota's water-drinking test. In this study, we used the dysphagia outcome and severity scale as the primary outcome indicator because it has high reliability [37]. To some extent, our study is valuable because we have included new studies, and our results have updated the stimulation protocol for tDCS. ...
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Dysphagia is one of the most common symptoms in patients after stroke onset, which has multiple unfavorable effects on quality of life and functional recovery. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation that is widely used to improve deglutition function. Recently, some studies have confirmed that tDCS enhances deglutition function after stroke. However, the number of evaluation indexes used in those studies was small, and the number of trials included was limited. Most importantly, the optimal stimulation protocol is still uncertain and the safety of tDCS has not been reviewed. Therefore, we conducted a systematic review and meta-analysis to address these shortcomings. Methods: Seven databases were searched entirely, including Pubmed, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), Wan-fang database, and the Chinese Scientific Journals Database (VIP) from inception to 31 December 2021. Two reviewers independently evaluated the eligibility of retrieved data according to the selection criteria and assessed the methodological quality of the studies using the Cochrane risk of bias tool. Outcomes, measures, and indicators used in this study included the dysphagia outcome and severity scale (DOSS), modified Mann assessment of swallowing ability (MMASA), functional oral intake scale (FOIS), functional dysphagia scale (FDS), and Kubota's water-drinking test (KWDT). Sensitivity and subgroup analyses were performed to evaluate the intervention effect more specifically. Results: Fifteen trials with a total of 787 participants (394 subjects in the tDCS groups were treated with true tDCS, and 393 subjects in the control groups were wait-listed or treated with sham tDCS) involving tDCS for dysphagia after stroke and were included in the meta-analysis. Results of this meta-analysis confirmed that tDCS had a positive effect on post-stroke dysphagia. Subgroup analyses revealed that bilateral and high-intensity stimulation with tDCS had a more significant impact on post-stroke dysphagia. Furthermore, no adverse events occurred during the application of tDCS for post-stroke dysphagia. Conclusion: tDCS can promote the recovery of deglutition function in patients with dysphagia after stroke. In addition, bilateral stimulation and high-intensity stimulation may have better effects. However, the safety evidence for tDCS and post-stroke dysphagia is insufficient.
... The penetration category corresponds to level 3 to 5 on the scale, and levels 6 to 8 According to the results of the VFSS, the patients' feeding methods were decided as follows: non-oral feeding, limited diet, or normal regular diet. Feeding status was presented as a dysphagia outcome and severity scale (DOSS) (29). It consists of 7-point levels (1-7), with higher scores indicating a normal diet. ...
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Background Stroke-related sarcopenia is caused by various factors, such as brain damage, systemic catabolic state, skeletal muscle imbalance, and malnutrition. In the long-term care plan after stroke, appropriate rehabilitation strategies to achieve maximum functional improvement and prevent the development of sarcopenia are important. This study has investigated the effect of branched-chain amino acid (BCAA) supplementation on sarcopenia after stroke. We also evaluated the effect of BCAA on functional improvement during the intensive rehabilitation period. Methods Patients with subacute stroke with stroke-related disabilities were enrolled and given dietary supplement powder containing BCAAs for 1 month. These BCAAs were supplied through the nutrition team during feeding time. Patients whose age, sex, and stroke lesions were similar to those of the study group were enrolled in the control group through medical record review. Both groups received personalized intensive inpatient rehabilitation therapy in a single-unit rehabilitation center. All patients' target calories were calculated regularly by the nutritional support team in our institution. Sarcopenia status was evaluated using grip strength and the skeletal muscle index (SMI), which was assessed by dual-energy X-ray absorptiometry (DEXA). The functional status associated with stroke was evaluated every month, including activities of daily living, balance, gait, and swallowing. Results A total of 54 patients were enrolled, with 27 patients in each of the two groups. The study group showed significantly greater improvement in SMI after intervention than the control group. Both groups improved functionally over time, but the improvement in the study group was significantly greater than that in the control group. Univariate analysis revealed that patients with better functional status had a greater SMI with a combination of BCAA supplementation and intensive rehabilitation therapy. Conclusion Our results showed a positive effect of BCAA supplementation on sarcopenia after stroke. We also found that nutritional support helps functional improvement during neurological recovery. These results suggest that comprehensive rehabilitation intervention combined with BCAA supplementation could be a helpful option during the critical period of post-stroke neurological recovery.
Resumen Inrtroducción La disfagia orofaríngea puede comportar complicaciones médicas, y una disminución de la calidad de vida. Aunque existe una amplia diversidad de procedimientos instrumentales y clínicos para valorarla, el consenso para su valoración holística es todavía insuficiente o poco detallado. El presente artículo tiene como objetivo presentar el diseño de un modelo de exploración holística de la disfagia orofaríngea que tenga en cuenta los componentes de la Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud (CIF) y que se pueda realizar tanto en modalidad presencial como semipresencial utilizando herramientas de las Tecnologías de la Información y Comunicación (TIC). Material y métodos Se realiza una revisión no sistemática de la literatura con el fin de seleccionar las herramientas de valoración de la disfagia orofaríngea validadas y con mayor grado de recomendación. Estas herramientas se analizan por un grupo de expertos en disfagia del Hospital de la Santa Creu i Sant Pau de Barcelona para diseñar un modelo de exploración holística. Resultados Este modelo de evaluación incluye una valoración al inicio y otra al final del tratamiento, así como un seguimiento continuo durante el proceso de rehabilitación. Se implementa de forma semipresencial y multidisciplinar con la finalidad de comprender la disfagia orofaríngea holísticamente para diseñar y monitorizar un plan terapéutico individualizado. Conclusiones La evaluación de la disfagia orofaríngea debe ubicarse en el marco biopsicosocial propuesto por la CIF. La aplicación de las TIC en las intervenciones semipresenciales lo facilitan.
Introduction: Cerebellum might be active during the task of swallowing. Little is known whether cerebellar repetitive transcranial magnetic stimulation (rTMS) could improve post-stroke dysphagia (PSD) due to occlusion in the posterior circulation. This paper describes the rationale and design of a randomized controlled trial that aims to determine the effect of cerebellar rTMS on dysphagia due to posterior circulation stroke. Methods and analysis: Thirty patients with PSD due to occlusion in the posterior circulation will be randomly divided to receive real (n = 20) or sham (n = 10) cerebellar rTMS. Patients in the real rTMS group will receive 250 pulses rTMS at a low intensity with 10 Hz frequency for 10 days (five consecutive days per week). The severity of dysphagia will be assessed with videofluoroscopic swallowing study (VFSS) using the Rosenbek penetration aspiration scale (PAS), the pharyngeal constriction ratio (PCR), and the dysphagia outcome and severity scale (DOSS) before and immediately after the last session and then again after 1 and 3 months. The functional magnetic resonance imaging (fMRI) will be assessed before and after the last session and then again after 1 month and 3 months. The primary outcome is the improvement of swallowing function determined by PAS, PCR, and DOSS. The secondary outcomes include changes in brain connectivity network detected using fMRI. Discussion: This study will determine whether cerebellar rTMS improves dysphagia due to posterior circulation stroke in Chinese patients. Our findings will contribute to a new approach for swallowing function recovery after posterior circulation stroke.
Prematurity is one of the main causes of risk factors for Newborns (NBs), as it actively affects the development of newborns and its complications, often resulting in the inability to provide breastfeeding in the first days of life. Therefore, the present study aims to portray the speech therapy assistance to preterm newborns in a neonatal Intensive Care Unit (ICU) in the region of the archipelago of Marajó/PA. This is a qualitative, retrospective study in which a search and analysis of the patient’s chart was carried out. Through speech therapy, qualified assistance can be given to the patient, ensuring safe food, reintroduction of oral feeding and hospital discharge. Thus, the role of the speech therapy in the neonatal and pediatric ICU is of paramount importance, as this professional is an active member of the multidisciplinary team.
Objective To evaluate the response to treatment with intravenous (IVIg) and subcutaneous (20%SCIg) immunoglobulin in our series of patients with Inflammatory idiopathic myopathies (IIM) by the means of artificial intelligence. Background IIM are rare diseases mainly involving the skeletal muscle with particular clinical, laboratory and radiological characteristics. Artificial intelligence (AI) represents computer processes which allows to perform complex calculations and data analyses, with the least human intervention. Recently, the use an AI in medicine significantly expanded, especially through machine learning (ML) which analyses huge amounts of information and accordingly makes decisions, and deep learning (DL) which uses artificial neural networks to analyse data and automatically learn. Methods In this study, we employed AI in the evaluation of the response to treatment with IVIg and 20%SCIg in our series of patients with IIM. The diagnoses were determined on the established EULAR/ACR criteria. The treatment response was evaluated employing the following: serum creatine kinase levels, muscle strength (MMT8 score), disease activity (MITAX score) and disability (HAQ-DI score). We evaluated all the above parameters, applying, with R, different supervised ML algorithms, including Least Absolute Shrinkage and Selection Operator, Ridge, Elastic Net, Classification and Regression Trees and Random Forest to estimate the most important predictors for a good response to IVIg and 20%SCIg treatment. Results and conclusion By the means of AI we have been able to identify the scores that best predict a good response to IVIg and 20%SCIg treatment. The muscle strength as evaluated by MMT8 score at the follow-up is predicted by the presence of dysphagia and of skin disorders, and the myositis activity index (MITAX) at the beginning of the treatment. The relationship between muscle strength and MITAX indicates a better action of IVIg therapy in patients with more active systemic disease. Considering our results, Elastic Net and similar approaches were seen to be the most viable, efficient, and effective ML methods for predicting the clinical outcome (MMT8 and MITAX at most) in myositis.
Objective To investigate the relationship between Handgrip Strength (HGS), dysphagia classification, nutritional aspects, and Pharyngeal Transit Time (PTT) in subjects with Chronic Obstructive Pulmonary Disease (COPD). Methods Study based on the analysis of secondary data from a database. The sample comprised 15 COPD patients of both sexes and a mean age of 65.7 years. We collected information on HGS, videofluoroscopic swallowing study, Volume-Viscosity Swallow Test (V-VST), and Body Mass Index (BMI). We applied correlation, effect size, and logistic regression tests at the 5% significance level. Results Most individuals had severe COPD (66.7%), mean dominant HGS of 28.2, and non-dominant HGS of 25.3. Five subjects were malnourished, five were well-nourished, and five were obese. Most of them had normal swallowing (40%), normal V-VST results (60%), and PTT of 0.89 s (liquid) and 0.81 s (pudding-thick). There was no significant correlation between the swallowing classification and the other variables. We obtained a significant correlation (p = 0.015), though weak (r = −0.611), between non-dominant HGS and PTT. Regarding the binary logistic regression, HGS variables and HGS asymmetry were not enough to be considered a risk to clinically abnormal swallowing (V-VST). Conclusion Subjects with COPD in this study had a longer PTT than reported in the literature for normal subjects and a weak correlation between PTT and non-dominant HGS. The variables related to muscle condition were not considered predictors for abnormal swallowing. Level of evidence 3.
Background and context : Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by growing ossifications of spinal entheses and tendons, which may cause trachea and esophagus compression when located anteriorly in the cervical spine. Purpose : Our previous systematic review on the epidemiological and clinical knowledge of dysphagia and airway obstruction caused by cervical DISH was updated, with a focus on (surgical) treatment and outcomes. Study design : A systematic review of the literature was performed. Methods : Publications in Medline and EMBASE from July 2010 to June 2021 were searched. Two investigators performed data extraction and study specific quality assessment. Results : A total of 138 articles (112 case reports and 26 case series) were included, describing 419 patients with dysphagia and/or airway obstruction. The mean age of the patient group was 67.3 years (range: 35–91 years), and 85.4% was male. An evident increase of published cases was observed within the last decade. Surgical treatment was chosen for 66% of patients with the anterolateral approach most commonly used. The total complication rate after surgery was 22.1%, with 12.7% occurring within 1 month after intervention. Improvement of dysphagia was observed in 95.5% of operated patients. After a mean follow-up of 3.7 years (range: 0.4-9.0 years), dysphagia recurred in 12 surgically treated patients (4%), of which 5 patients had osteophyte regrowth. Conclusion : The amount of published cases of dysphagia in patients with DISH has doubled in the last decade compared to our previous review. Yet, randomized studies or guidelines on the treatment or prevention on recurrence are lacking. Surgical treatment is effective and has low (major) complication rates. Common trends established across the cases in our study may help improve our understanding and management of dysphagia and airway obstruction in cervical DISH.
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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.
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A prospective study was undertaken to define the incidence, duration, and consequences of dysphagia in an unselected group of 91 consecutive patients who had suffered acute stroke. The site of the present lesion and of any previous stroke was determined clinically and was confirmed by computed tomography of the brain or necropsy in 40 cases. Of 41 patients who had dysphagia on admission, 37 had had a stroke in one cerebral hemisphere. Only seven patients showed evidence of lesions in both hemispheres. Nineteen of 22 patients who survived a stroke in a hemisphere regained their ability to swallow within 14 days. Dysphagia in patients who had had a stroke in a cerebral hemisphere was associated in this study with a higher incidence of chest infections, dehydration, and death.
The effects of laryngotracheoesophageal cleft, rheumatoid arthritis, gastroesophageal reflux disease, supracricoid partial laryngectomy with cricohyoidopexy, and postsurgical unilateral recurrent nerve paralysis on swallowing function are examined. Procedures for screening patients for symptoms of swallowing problems and diagnostic techniques that define swallowing anatomy and physiology are compared and contrasted. Surgical and behavioral treatments for swallowing disorders are described.
Clinical and videofluoroscopic evaluation of swallowing were correlated to determine their agreement and relationship to feeding recommendations. We reviewed a total of 148 patients with swallowing difficulties, of which 93 (45 women, 48 men; mean age 62 years) were evaluated by both clinical and radiographic examinations. A variety of materials were used for clinical bedside evaluation of oral and pharyngeal function. Radiographic examination was done with variable viscosity materials and videotape recording of the oral cavity and pharynx. The severity of oral and pharyngeal abnormalities was graded and findings of the examinations were compared. The combined results of both evaluations generated an index of swallowing difficulty which was correlated to the type of diet used if oral feeding was recommended or to a nonoral route of nutrition. In the assessment of oral and pharyngeal dysfunction, clinical evaluation and radiographic examination correlated closely in 94% of patients; however, the status of pharyngeal function was not determined in 61 (66%) of the 93 patients by clinical examination alone. The combined swallowing index was calculated in 89 patients and its severity correlated significantly with the type of feeding recommended; 64 patients were placed on one of three types of diets and 25 had enteral feedings. In conclusion, combined clinical and radiographic examinations correlated well, but clinical evaluation alone was limited by failure to evaluate the pharynx in many patients. The swallowing severity correlated well with final feeding recommendations.
The prevalence of swallowing disorders among the adult population of two major medical centers during a 3-week period was investigated. Data on the distribution of swallowing disorders among hospital services were analyzed, yielding a consistent incidence of 12–13% of the patients at each hospital. Implications for hospital planning and for further research are discussed.
Cineradiographic examinations of 72 patients with dysphagia and normal or abnormal studies demonstrating a range of pharyngeal dysfunctions during swallowing were retrospectively reviewed independently by six radiologists. The interobserver variability was then assessed. There was high concordance for the assessment of contrast medium reaching into the trachea, absent pharyngeal constriction, and the presence of Zenker diverticula. The concordance was less for normal pharyngeal function as well as decreased pharyngeal constriction and cricopharyngeal muscle impression less than 50%. The number of disagreements varied according to the observer's experience. Cineradiographic examinations of pharyngeal function during swallow had an acceptable degree of interobserver variability and can be a useful tool for the evaluation of pharyngeal function in patients with dysphagia.
Thirty-eight CVA patients with swallowing disorders were studied videofluorographically (VFG) to determine: (1) the nature of their swallowing disorders, (2) the relationship between the site of the cerebrovascular accident and the nature of the swallowing disorder(s) exhibited and (3) the frequency and etiology of any aspiration present. The 38 CVA patients exhibited a variety of physiologic disturbances in swallowing, usually occurring in combination rather than as isolated disorders. A delayed swallowing reflex was the most frequent disorder seen in all patient groups. Reduced pharyngeal peristalsis was the next most frequent disorder, followed by reduced tongue control. Only brainstem CVA patients exhibited reduced laryngeal closure. Two patients (no right CVAs) experienced cricopharyngeal dysfunction. Few differences in nature of swallowing disorders were seen according to lesion location. Approximately one third of the patients aspirated, most frequently because of delayed triggering of the swallowing reflex. All aspiration occurred because of disorders in the pharyngeal stage of the swallow, emphasizing the importance of VFG evaluation of dysphagia in CVA patients.
Dysphagia may in rare instances be a presenting feature of unilateral cerebral lesions. Normally, bilateral lesions are necessary to cause neurological disturbance of swallowing but there appear to be occasional subjects where this is not so. Cases are presented and the literature reviewed to illustrate this. The dysphagia may occur in isolation and is not necessarily accompanied by dysarthria, facial apraxia, or obvious paralysis. The lesion may be on either side and usually involves the low posterior frontal region. Cases that have come to necropsy have shown involvement of the lowest part of the precentral gyrus or the posterior part of the inferior frontal gyrus.