Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Choosing the Feeding Method for Stroke Patients with Dysphagia

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However, the inter-rater reliability of the VDS was low in a previous study. To overcome the mentioned limitations of the VDS, the modified version of the VDS (mVDS) was created and clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia. Methods: The videofluoroscopic swallowing study (VFSS) data of 56 stroke patients with dysphagia were collected retrospectively. We investigated the presence of aspiration pneumonia and the selected feeding method. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia after stroke. Univariate logistic regression and receiver operating characteristic analyses were used in the data analysis. Results: The inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability. In all patients, the supratentorial stroke subgroup, and the infratentorial stroke subgroup, the mVDS scores were statistically correlated with the feeding method selected (p<0.05) and the presence of aspiration pneumonia (p<0.05). Conclusions: The mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies for interpreting the VFSS findings in stroke patients with dysphagia. Further studies with a greater number of patients and various stroke etiologies are required for more generalized application of the mVDS. Health Economics & Outcomes Research Scientific Communication deglutition swallowing difficulty dysphagia Videofluoroscopic Dysphagia Scale videofluoroscopic swallowing study modified version of the Videofluoroscopic Dysphagia Scale Figures Figure 1 Introduction Dysphagia is a serious clinical problem that can decrease the quality of life and lead to lethal conditions, such as aspiration pneumonia.[ 1 – 3 ] Although few clinical bedside tests are used universally, the videofluoroscopic swallowing study (VFSS) has been commonly accepted as the gold standard in assessing dysphagia.[ 4 ] The VFSS can detect aspiration and penetration in addition to various abnormalities in the oral, pharyngeal, and esophageal phases.[ 5 ] Therefore, it provides some guidance in determining which swallowing therapy should be applied and what type of diet should be adequate. Among numerous methods to predict and quantify the prognosis of dysphagia, the Functional Dysphagia Scale is a useful tool that correlates well with the American Speech-Language-Hearing Association National Outcomes Measurement System.[ 6 , 7 ] However, despite its value in interpreting the severity of dysphagia, it does not predict the long-term prognosis, which is important because of the close relationship among prolonged dysphagia, high mortality, and a low respiratory tract infection rate.[ 8 ] The Videofluoroscopic Dysphagia Scale (VDS) is used to predict the long-term prognosis of dysphagia in patients with stroke.[ 8 , 9 ] Han et al. used the VDS to assess the long-term prognosis of dysphagia based on the development of any aspiration or penetration episode after 6 months from the onset of dysphagia.[ 10 ] The VDS consists of 14 categories and shows good correlation with an aspiration or a penetration symptom that occurs 6 months after the initial onset of dysphagia. [ 10 ] The 14 items of the VDS (Table 1 ) represent oral functions (lip closure, mastication, bolus formation, premature bolus loss, apraxia, and oral transit time) and pharyngeal functions (pharyngeal triggering, laryngeal elevation and epiglottic closure, pharyngeal transit time, pharyngeal coating, vallecular and pyriform sinus residues, and aspiration) that can be observed from the VFSS video.[ 10 ] Table 1 Videofluoroscopic Dysphagia Scale parameter score lip closure intact 0 4 inadequate 2 none 4 bolus formation intact 0 6 inadequate 3 none 6 mastication intact 0 8 inadequate 4 none 8 apraxia none 0 4.5 mild 1.5 moderate 3 severe 4.5 tongue-to-palate contact intact 0 10 inadequate 5 none 10 premature bolus loss none 0 4.5 50% 4.5 oral transit time ≤ 1.5 seconds 0 3 > 1.5 seconds 3 triggering of pharyngeal swallow normal 0 delayed 4.5 vallecular residue none 0 6 50% 6 laryngeal elevation normal 0 9 impaired 9 pyriform sinus residue none 0 13.5 50% 13.5 coating of pharyngeal wall no 0 9 yes 9 pharyngeal transit time ≤ 1.0 second 0 6 > 1.0 second 6 aspiration none 0 12 supraglottic penetration 6 subglottic aspiration 12 total score 100 The VDS can also quantify the severity of dysphagia in total scores, but limitations regarding the subjectivity of the results have been noted in previous studies. Kim et al. reported the inter-rater reliability results of the VDS among 10 physiatrists.[ 11 ] In their study, the inter-rater reliability of the VDS showed a low rate of agreement (κ < 0.20), especially in bolus formation (κ = 0.153), mastication (κ = 0.123), apraxia (κ = 0.099), tongue to palate contact (κ = 0.153), premature bolus loss (κ = 0.060), and pharyngeal transit time (κ = 0.165).[ 11 ] Other parameters showed a fair rate of agreement (κ > 0.2, κ < 0.4).[ 11 ] Such results suggest that the VDS can be subjective according to interpreters, especially for several parameters, such as apraxia, tongue to palate contact, premature bolus loss, or bolus formation. Subjectivity is also possible because of the ambiguous criterion of several parameters of the VDS. Therefore, to overcome the mentioned limitations of the VDS, some parameters of the VDS were modified in the present study. Furthermore, the modified version of the VDS (mVDS) was clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia. Methods Ethics statements The protocol for this study was approved by the Institutional Review Board of Daegu Fatima Hospital. This study was conducted according to the Declaration of Helsinki for human experiments. Written informed consent was obtained from all participants. Study design and population Data of stroke patients with dysphagia who underwent a VFSS for the first time at Daegu Fatima Hospital between April 2019 and January 2021, were collected retrospectively. Patients who had any symptoms of difficulty in swallowing were recruited. We obtained clinical data, such as sex, age, stroke onset, the Mini-Mental State Examination score, modified Bethel index score, type of lesions of stroke (surpatentorial or infratentorial lesions), history of aspiration pneumonia, and duration from stroke onset. The criteria for inclusion were as follows: (1) a history of aspiration symptoms, such as coughing or choking; (2) symptoms clinically indicative of dysphagia, such as reduced gag reflex or delayed swallowing reflex; and (3) a history of using alternative feeding methods, such as a nasogastric tube. Patients who could not sit or those who had difficulty maintaining consciousness were excluded. Aspiration pneumonia A retrospective review was conducted to investigate the development of aspiration pneumonia within 1 month before and after a VFSS in stroke patients with dysphagia.[ 12 , 13 ] The following data were collected: symptoms, such as coughing during feeding; the presence of sputum, dyspnea, or fever; chest X-ray findings; blood laboratory findings (white blood cell [WBC] counts, C-reactive protein [CRP] level, and erythrocyte sedimentation rate); and use of antibiotics.[ 12 , 13 ] Although a definitive diagnosis of aspiration is difficult and the diagnostic criteria for aspiration pneumonia are slightly different across studies, patients who met all of the following criteria were considered to have aspiration pneumonia in the present study: (1) the presence of both objective signs (coarse lung sounds, the presence of lung infiltration on chest X-ray, and systemic inflammation based on blood laboratory findings, such as increased CRP levels and WBC counts) and subjective symptoms (fever, cough, and increased purulent sputum), (2) clinical suspicion of aspiration (delayed swallowing or coughing during swallowing), and (3) no evidence of microorganisms, such as Legionella or Mycoplasma , which are common pathogens in atypical pneumonia.[ 12 , 13 ] In addition, the clinical reports from the Internal Medicine Department were used to diagnose aspiration pneumonia. The VFSS protocol The VFSS was performed with a fluoroscopic device and recorded as a video file. During the VFSS, patients consecutively swallowed the following materials that had a stepwise consistency: water, nectar (51–350 cP), rice porridge (351-1,750 cP), and boiled rice (> 1,750 cP).[ 14 ] The materials were mixed with liquid barium, and the patient swallowed them while in a relaxed sitting position. Dynamic fluoroscopic images were obtained in the anterior-posterior and lateral views and were recorded at 30 frames per second. The VFSS images were analyzed according to the Penetration-Aspiration Scale (PAS) and considered positive for aspiration if the PAS score was > 5.[ 15 ] All studies were reviewed by two physiatrists who had at least 7 years of experience in interpreting VFSS results. Patient information, including age, sex, and underlying diseases, was withheld from the interpreters. The interpreters only observed the patients using the movie files on the laptop, described their findings, and chose a feeding method (non-oral feeding versus oral feeding) based on the VFSS results. Modification of the VDS The mVDS was developed based on a study regarding the inter-rater reliability of the VDS.[ 8 , 9 ] Among the VDS categories, the ones with a κ value < 0.2 (bolus formation, mastication, apraxia, tongue in palate contact, and pharyngeal transit time) were modified. As mentioned by previous researchers, such categories had somewhat ambiguous guidelines and three to four multiple selectable choices, which lead to low reliability.[ 11 ] Therefore, we modified the categories according to a binary scale or deleted the ambiguous categories. The mVDS was drafted as follows (Table 2 ). The bolus formation and tongue to palate contact categories, which had multiple selectable choices, were deleted because of their ambiguous criteria. The lip closure and mastication categories were modified according to a binary scale of intact/not intact. The pharyngeal transit time category was based on a binary scale, but it was deleted because it had a low κ value, as it is thought to have some similarity with triggering of the pharyngeal reflex. The laryngeal elevation category had an ambiguous guideline, and the κ value was low (0.202). We changed the category to laryngeal inversion, which was reported to be an important factor in the swallowing process in a previous study because laryngeal elevation and epiglottis inversion are a result of a combination of contraction/relaxation of the suprahyoid and infrahyoid muscles.[ 16 ] Table 2 Modified version of the Videofluoroscopic Dysphagia Scale parameters score lip closure intact / not intact 0 / 6 massification possible / not possible 0 / 11.5 oral transit time ≤ 1.5 seconds / >1.5 seconds 0 / 4 triggering pharyngeal swallow (swallowing reflex) intact / delayed 0 / 7 epiglottis inversion yes / no 0 / 13 valleculae residue 0% / <10% / ≥10%, < 50% / ≥50% 0 / 3 / 6 / 9 pyriformis residue 0% / <10% / ≥10%, < 50% / ≥50% 0 / 6.5 / 13 / 19.5 pharyngeal wall coating no / yes 0 / 13 aspiration intact / penetration / aspiration 0 / 8.5 / 17 total score 100 Originally, to measure these VFSS findings as objective quantitative scores, the VDS with a sum of 100 points was created according to the odds ratios of various prognostic factors.[ 8 ] After modification of the parameters of the VDS, we re-balanced each category’s score of the mVDS, which had a sum of 100 points (Table 2 ). Statistical analysis The intra-class correlation coefficient (ICC) model 2.1 of the VDS was used to test the inter-rater reliability based on the mVDS scores provided by the interpreters. The ICC model was used because it can be utilized for scale and ordinal variables. Ordinal variables equivalent to the weighted κ/ICC values > 0.80 were considered very good, and those with κ/ICC values between 0.60 and 0.80 were considered good. To evaluate the correlation between the mVDS and the selected feeding method and between the mVDS and the presence of aspiration pneumonia after stroke, a univariate logistic regression analysis with the enter method was used. To evaluate the accuracy of predictive factors for oral feeding or non-oral feeding based on the VFSS findings, we performed a receiver operating characteristic (ROC) analysis. Statistical analysis was conducted using the MedCalc program (MedCalc Software, Ostend, Belgium) and SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Results Patients’ characteristics Fifty-six stroke patients with dysphagia were enrolled in this study. Among them, 33 patients were male and 23 were female. Thirty-seven patients had ischemic stroke and 19 had hemorrhagic stroke. Thirty-eight patients had supratentorial stroke and 18 had infratentorial stroke. The patients’ demographic data are presented in Table 3 . Table 3 Characteristics of stroke patients with dysphagia in the present study characteristics mean ± standard deviation (median ; 25% − 75%) age (year) 70.96 ± 14.456 (77.00 ; 63.25–80.75) sex (male:female) 33 (58.9%) : 23 (41.1%) duration of disease (day) 422.64 ± 714.519 (255.00 ; 169–296.25) PAS grade 3.80 ± 2.331 (3.00 ; 2.00–5.75) MMSE score 15.2453 ± 10.03629 (17.0000 ; 4.5000–24.0000) MBI score 29.6038 ± 21.61938 (26.0000 ; 12.0000 − 43.0000) supra/infra-tentorial stroke 38 (67.9%) : 18 (32.1%) mVDS scores lip closure 0.32 ± 1.363 (0.00 ; 0.00–0.00) massification 4.107 ± 5.5602 (0.000 ; 25% − 75%) oral transit time 0.57 ± 1.412 (0.00 ; 0.00–0.00) triggering pharyngeal swallowing 6.88 ± 0.935 (7.00 ; 7.00–7.00) epiglottis inversion 0.46 ± 2.434 (0.00 ; 0.00–0.00) valleculae residue 3.48 ± 1.695 (3.00 ; 3.00–3.00) pyriformis residue 4.063 ± 4.5647 (3.250 ; 0.000–6.500) pharyngeal wall coating 2.55 ± 5.212 (0.00 ; 0.00–0.00) aspiration 9.714 ± 6.5698 (8.500 ; 8.500–17.000) total score 36.277 ± 18.6411 (32.500 ; 21.500–48.375) PAS: penetration-aspiration scale, mVDS: modified videofluoroscopic dysphaga scale, MMSE: mini-mental status examination, MBI; modified Bathel Index Inter-rater reliability of the mVDS The inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability. Correlation between the mVDS and the selected feeding method based on the VFSS findings In all patients, the mVDS score was statistically correlated with the selected feeding method (p < 0.05) (Table 4 ). In the ROC curve analysis, the area under the ROC curve (AUC) for the selected feeding method was 0.904 (95% confidence interval [CI], 0.795–0.966; p < 0.0001). The optimal cut-off value for the allowance of oral feeding obtained from the maximal Youden index was a score of ≤ 36.5 based on the mVDS (sensitivity, 76.19%; specificity, 92.86%) for the allowance of oral feeding (Fig. 1 -A). Additionally, a score of ≤ 32 based on the mVDS showed a sensitivity of 66.67% and specificity of 100% for the allowance of oral feeding. For non-oral feeding, the optimal cut-off value obtained from the maximal Youden index was a score of ≥ 36.5 based on the mVDS (sensitivity, 92.86%; specificity, 76.19%). Additionally, a score of ≥ 67 showed a sensitivity of 28.57% and specificity of 100% for non-oral feeding. Table 4 Univariate logistic regression analysis (with the enter method) of the association between the modified version of the Videofluoroscopic Dysphagia Scale scores and the selection of the oral feeding method. Parameter Beta coefficient Standard error OR (95% CI) p-value Total stroke patients with dysphagia mVDS score -0.114 0.031 0.892 (0.839–0.949) < 0.001 Patients with supratentorial stroke mVDS score -0.121 0.038 0.886 (0.823–0.954) 0.001 Patients with infratentorial stroke mVDS score -0.087 0.055 0.917 (0.824–1.020) 0.011 mVDS, modified version of the Videofluoroscopic Dysphagia Scale; OR, odds ratio; CI, confidence interval. In the subgroup analysis of patients with supratentorial stroke, the mVDS score was also statistically correlated with the selected feeding method (p < 0.05). In the ROC curve analysis, the AUC for the selected feeding method was 0.926 (95% CI, 0.793–0.986; p < 0.0001). The optimal cut-off value obtained from the maximal Youden index was a score of ≤ 32 based on the mVDS (sensitivity, 74.07%; specificity, 100.0%) for the allowance of oral feeding (Fig. 1 -B). Additionally, a score of ≥ 67 showed a sensitivity of 27.27% and specificity of 100% for non-oral feeding. In the subgroup analysis of patients with infratentorial stroke, the mVDS score was also statistically correlated with the selected feeding method (p < 0.05). In ROC curve analysis, the AUC for the selected feeding method was 0.822 (95% CI, 0.573–0.959; p = 0.0067). The optimal cut-off value obtained from the maximal Youden index was a score of ≤ 34.5 based on the mVDS (sensitivity, 73.33%; specificity, 100.0%) for the allowance of oral feeding (Fig. 1 -C). Additionally, a score of ≥ 51 showed a sensitivity of 33.33% and specificity of 100% for non-oral feeding. Correlation between the mVDS and the development of aspiration pneumonia In the univariate logistic regression analysis, the mVDS score was significantly correlated with the presence of aspiration pneumonia after stroke (p < 0.05) (Table 5 ). Table 5 Univariate logistic regression analysis (with the enter method) of the association between the modified version of the Videofluoroscopic Dysphagia Scale and the development of aspiration pneumonia Parameter Beta coefficient Standard error OR (95% CI) p-value Development of aspiration pneumonia mVDS score 0.051 0.020 1.053 (1.012–1.095) < 0.001 mVDS, modified version of the Videofluoroscopic Dysphagia Scale; OR, odds ratio; CI, confidence interval. Discussion In this study, the mVDS scores showed a statistically significant correlation with the selection of oral feeding in stroke patients with dysphagia. The result of the subgroup analysis, based on the lesion location, was also statistically significant. Interestingly, the analysis of all patients and patients with supratentorial stroke showed that an mVDS score of 32 had a specificity of 100%, whereas the analysis of patients with infratentorial lesions showed that an mVDS score of 34.5 had a specificity of 100%. Therefore, in general, an mVDS score of 32 is the reference point for selecting oral feeding, with a specificity of 100%. For non-oral feeding in all stroke patients with dysphagia and in those with supratentorial stroke, an mVDS score of > 60 had a specificity of 100%. However, in patients with infratentorial stroke, an mVDS score of ≥ 51 or higher had a specificity of 100%. One possible explanation for this discrepancy is the difference in the total number of patients in the two subgroups. The number of patients with infratentorial stroke was smaller than that of patients with infratentorial stroke, and this may have led to the different statistical outcome. Another possible explanation is the aspiration category of the mVDS. The score of the aspiration category of the mVDS does not change in accordance with how often the aspiration was detected during the VFSS. Patients with infratentorial stroke may have shown a higher incidence of aspiration during the VFSS than those with supratentorial stroke;[ 17 ] therefore, they may have not been able to feed orally, but it would not have been accounted for in the mVDS score. In other words, the same mVDS score could still mean that the severity of swallowing difficulty may have been more in patients with infratentorial stroke than in those with supratentorial stroke. According to the inter-rater reliability test, the mVDS score showed an ICC of 0.886, which was higher than that of the original VDS score (0.556).[ 11 ] This may be due to the modification made to the categories that were somewhat ambiguous to score or had multiple choices.[ 11 ] Despite such a modification, the mVDS score was significantly correlated with the selection of oral feeding and development of aspiration pneumonia, which are important diagnosis of VFSS. Considering such correlations, it is possible to assume that the mVDS can sufficiently describe and analyze the VFSS results. However, nine of the 14 categories of the VDS have at least three selectable values, and the distinguishing between them is somewhat ambiguous.[ 11 ] This may lead to low inter-rater reliability. In the mVDS, similar to the VDS, a higher score indicates a greater diet limitation and more severe dysphagia. The mVDS can produce numerical data regarding swallowing function by using comprehensive VFSS findings with a relatively high inter-rater reliability. Therefore, the mVDS provides more intuitive data than conventional VFSS interpretation, which is usually focused on the presence of aspiration or penetration. There are several limitations to our study. First, the total number of enrolled patients was relatively small. Therefore, it may be challenging to make a general conclusion. Nonetheless, the result showed consistency in all stroke patients with dysphagia, the supratentorial stroke subgroup, and the infratentorial stroke subgroup. However, further studies with a greater number of participants are needed to make a more generalized conclusion. Second, the study was limited to stroke patients with dysphagia. Considering the application of the VFSS in the broad spectrum of etiology, it is crucial to apply the mVDS to diseases other than stroke. Conclusions The mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies to interpret the VFSS findings in stroke patients with dysphagia. In patients with an mVDS score of ≤ 32, it should be considered safe to select oral feeding as the feeding method. Declarations Acknowledgement: None Financial Disclosure: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Disclosure: None Conflict of interest: The authors report no conflict of interest or financial support. Funds: No Authors contribution: Byung Joo Lee: Writing – original draft, and Writing – review and editing Hyoshin Eo: Data acquisition, Data curation Changbae Lee: Data acquisition, Data curation Donghwi Park: Conceptualization, Formal analysis, Writing – original draft, and Writing – review and editing References Karkos PD, Papouliakos S, Karkos CD, Theochari EG. Current evaluation of the dysphagic patient. Hippokratia 2009 ; 13:141-6. Chang MC, Park JS, Lee BJ, Park D. Effectiveness of pharmacologic treatment for dysphagia in Parkinson's disease: a narrative review. Neurol Sci 2020 . Park D, Suh JH, Kim H, Ryu JS. The Effect of Four-Channel Neuromuscular Electrical Stimulation on Swallowing Kinematics and Pressures: A Pilot Study. Am J Phys Med Rehabil 2019 ; 98:1051-9. Costa MM. Videofluoroscopy: the gold standard exam for studying swallowing and its dysfunction. Arq Gastroenterol 2010 ; 47:327-8. Park D, Oh Y, Ryu JS. Findings of Abnormal Videofluoroscopic Swallowing Study Identified by High-Resolution Manometry Parameters. Arch Phys Med Rehabil 2016 ; 97:421-8. Schooling TL. Lessons from the National Outcomes Measurement System (NOMS). Semin Speech Lang 2003 ; 24:245-56. Lee JH, Lee KW, Kim SB, Lee SJ, Chun SM, Jung SM. The Functional Dysphagia Scale Is a Useful Tool for Predicting Aspiration Pneumonia in Patients With Parkinson Disease. Ann Rehabil Med 2016 ; 40:440-6. Kim J, Oh BM, Kim JY, Lee GJ, Lee SA, Han TR. Validation of the videofluoroscopic dysphagia scale in various etiologies. Dysphagia 2014 ; 29:438-43. Mo SJ, Jeong HJ, Han YH, Hwang K, Choi JK. Association of Brain Lesions and Videofluoroscopic Dysphagia Scale Parameters on Patients With Acute Cerebral Infarctions. Ann Rehabil Med 2018 ; 42:560-8. Han TR, Paik NJ, Park JW. Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies. Arch Phys Med Rehabil 2001 ; 82:677-82. Kim DH, Choi KH, Kim HM, et al. Inter-rater Reliability of Videofluoroscopic Dysphagia Scale. Ann Rehabil Med 2012 ; 36:791-6. Kim GE, Sung IY, Ko EJ, Choi KH, Kim JS. Comparison of Videofluoroscopic Swallowing Study and Radionuclide Salivagram for Aspiration Pneumonia in Children With Swallowing Difficulty. Ann Rehabil Med 2018 ; 42:52-8. Yu KJ, Moon H, Park D. Different clinical predictors of aspiration pneumonia in dysphagic stroke patients related to stroke lesion: A STROBE-complaint retrospective study. Medicine (Baltimore) 2018 ; 97:e13968. Yu KJ, Park D. Clinical characteristics of dysphagic stroke patients with salivary aspiration: A STROBE-compliant retrospective study. Medicine (Baltimore) 2019 ; 98:e14977. Borders JC, Brates D. Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review. Dysphagia 2020 ; 35:583-97. A. Duarte JLdA, Ú. Martins, C. Magro, C. Lima, S. Araújo, N. Pereira, M. Coutinho, H. Marques. Epiglottic kinematics alterations and risk of laryngeal penetration-aspiration. Annals of Physical and Rehabilitation Medicine 2018 ; 61:e189-e90. Kim YK, Cha JH, Lee KY. Comparison of Dysphagia Between Infratentorial and Supratentorial Stroke Patients. Ann Rehabil Med 2019 ; 43:149-55. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 May, 2021 Read the published version in Healthcare → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-155745","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":9758087,"identity":"302140b7-b04d-49bd-a955-5c36eb4cd757","order_by":0,"name":"Byung Joo Lee","email":"","orcid":"","institution":"Daegu Fatima Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Byung","middleName":"Joo","lastName":"Lee","suffix":""},{"id":9758088,"identity":"a0f1da77-5e2b-42b8-a226-be27c6f07b74","order_by":1,"name":"Hyoshin Eo","email":"","orcid":"","institution":"Daegu Fatima Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hyoshin","middleName":"","lastName":"Eo","suffix":""},{"id":9758089,"identity":"d1d6a419-45b2-4a55-bae4-0f1218cd7caa","order_by":2,"name":"Changbae Lee","email":"","orcid":"","institution":"Ulsan University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Changbae","middleName":"","lastName":"Lee","suffix":""},{"id":9758090,"identity":"fef8ef52-1d30-41cd-9259-1186d2239630","order_by":3,"name":"Donghwi Park","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACA4YEIFlxAMw58IB4LWegWkBsHqK0MLZBtDAQpcWcPfnoho/z7sibix1+CLTljpw9IS2WPc/Sbs7c9sxw5+w0A6CWZ8aEHXYjx+w277bDjBtuJ4C0HE7sIUrL3zmH7TfcTv8A0lJPnBbGhsOJG27ngG1JIOgwsF96jh1OBmopOJBgcNiw5wABLcAQO3bjR81hW6DDNn/4UHFYnr2BkDVo7iRN+SgYBaNgFIwCHAAAx8NOhuv6CJYAAAAASUVORK5CYII=","orcid":"","institution":"Ulsan University Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Donghwi","middleName":"","lastName":"Park","suffix":""}],"badges":[],"createdAt":"2021-01-26 09:44:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-155745/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-155745/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.3390/healthcare9060632","type":"published","date":"2021-05-27T11:52:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":5556637,"identity":"d3e37c5e-a149-404e-8a1d-134bab9add29","added_by":"auto","created_at":"2021-02-02 20:29:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125783,"visible":true,"origin":"","legend":"(A) ROC curve of the mVDS score for the selection of oral feeding in stroke patients with dysphagia. The optimal cut-off value (dots on the curves) of the mVDS score, which was obtained from the maximal Youden index, was ≤36.5 (AUC, 0.904; 95% CI, 0.795–0.966; p\u003c0.0001; sensitivity, 76.19%; specificity, 92.86%). (B) ROC curve of the mVDS score for the selection of oral feeding in supratentorial stroke patients with dysphagia. The optimal cut-off value obtained from the maximal Youden index was a score of ≤32 based on the mVDS (AUC, 0.926; 95% CI, 0.793–0.986; p\u003c0.0001; sensitivity, 74.07%; specificity, 100.0%) for the selection of oral feeding. (C) ROC curve of the mVDS score for the selection of oral feeding in infratentorial stroke patients with dysphagia. The optimal cut-off value obtained from the maximal Youden index was a score of ≤32 based on the mVDS (AUC, 0.822; 95% CI, 0.573–0.959; p=0.0067; sensitivity, 73.33%; specificity, 100.0%) for the selection of oral feeding.\nROC, receiver operating characteristic; AUC, area under the receiver operating characteristic curve; CI, confidence interval; mVDS, modified version of the Videofluoroscopic Dysphagia Scale.\n","description":"","filename":"OnlineFigure1300dpi.png","url":"https://assets-eu.researchsquare.com/files/rs-155745/v1/cd6a1553d80284243830e0e3.png"},{"id":60220153,"identity":"368d2485-ced2-45ec-887a-4ed3c15f8ee2","added_by":"auto","created_at":"2024-07-13 11:53:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":822822,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-155745/v1/c989f34f-376c-444e-8dd7-809f0f2cf867.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Choosing the Feeding Method for Stroke Patients with Dysphagia","fulltext":[{"header":"Introduction","content":" \u003cp\u003eDysphagia is a serious clinical problem that can decrease the quality of life and lead to lethal conditions, such as aspiration pneumonia.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Although few clinical bedside tests are used universally, the videofluoroscopic swallowing study (VFSS) has been commonly accepted as the gold standard in assessing dysphagia.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The VFSS can detect aspiration and penetration in addition to various abnormalities in the oral, pharyngeal, and esophageal phases.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Therefore, it provides some guidance in determining which swallowing therapy should be applied and what type of diet should be adequate.\u003c/p\u003e \u003cp\u003eAmong numerous methods to predict and quantify the prognosis of dysphagia, the Functional Dysphagia Scale is a useful tool that correlates well with the American Speech-Language-Hearing Association National Outcomes Measurement System.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] However, despite its value in interpreting the severity of dysphagia, it does not predict the long-term prognosis, which is important because of the close relationship among prolonged dysphagia, high mortality, and a low respiratory tract infection rate.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe Videofluoroscopic Dysphagia Scale (VDS) is used to predict the long-term prognosis of dysphagia in patients with stroke.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Han et al. used the VDS to assess the long-term prognosis of dysphagia based on the development of any aspiration or penetration episode after 6 months from the onset of dysphagia.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The VDS consists of 14 categories and shows good correlation with an aspiration or a penetration symptom that occurs 6 months after the initial onset of dysphagia. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The 14 items of the VDS (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) represent oral functions (lip closure, mastication, bolus formation, premature bolus loss, apraxia, and oral transit time) and pharyngeal functions (pharyngeal triggering, laryngeal elevation and epiglottic closure, pharyngeal transit time, pharyngeal coating, vallecular and pyriform sinus residues, and aspiration) that can be observed from the VFSS video.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVideofluoroscopic Dysphagia Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e 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\u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ebolus formation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003emastication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eapraxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emoderate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003etongue-to-palate contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e 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align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eoral transit time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1.5 seconds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.5 seconds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003elaryngeal elevation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eimpaired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003epyriform sinus residue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ecoating of pharyngeal wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003epharyngeal transit time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1.0 second\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.0 second\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003easpiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esupraglottic penetration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esubglottic aspiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe VDS can also quantify the severity of dysphagia in total scores, but limitations regarding the subjectivity of the results have been noted in previous studies. Kim et al. reported the inter-rater reliability results of the VDS among 10 physiatrists.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] In their study, the inter-rater reliability of the VDS showed a low rate of agreement (κ\u0026thinsp;\u0026lt;\u0026thinsp;0.20), especially in bolus formation (κ\u0026thinsp;=\u0026thinsp;0.153), mastication (κ\u0026thinsp;=\u0026thinsp;0.123), apraxia (κ\u0026thinsp;=\u0026thinsp;0.099), tongue to palate contact (κ\u0026thinsp;=\u0026thinsp;0.153), premature bolus loss (κ\u0026thinsp;=\u0026thinsp;0.060), and pharyngeal transit time (κ\u0026thinsp;=\u0026thinsp;0.165).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Other parameters showed a fair rate of agreement (κ\u0026thinsp;\u0026gt;\u0026thinsp;0.2, κ\u0026thinsp;\u0026lt;\u0026thinsp;0.4).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Such results suggest that the VDS can be subjective according to interpreters, especially for several parameters, such as apraxia, tongue to palate contact, premature bolus loss, or bolus formation. Subjectivity is also possible because of the ambiguous criterion of several parameters of the VDS.\u003c/p\u003e \u003cp\u003eTherefore, to overcome the mentioned limitations of the VDS, some parameters of the VDS were modified in the present study. Furthermore, the modified version of the VDS (mVDS) was clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthics statements\u003c/h2\u003e\u003cp\u003e The protocol for this study was approved by the Institutional Review Board of Daegu Fatima Hospital. This study was conducted according to the Declaration of Helsinki for human experiments. Written informed consent was obtained from all participants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and population\u003c/h2\u003e\u003cp\u003eData of stroke patients with dysphagia who underwent a VFSS for the first time at Daegu Fatima Hospital between April 2019 and January 2021, were collected retrospectively. Patients who had any symptoms of difficulty in swallowing were recruited. We obtained clinical data, such as sex, age, stroke onset, the Mini-Mental State Examination score, modified Bethel index score, type of lesions of stroke (surpatentorial or infratentorial lesions), history of aspiration pneumonia, and duration from stroke onset.\u003c/p\u003e\u003cp\u003eThe criteria for inclusion were as follows: (1) a history of aspiration symptoms, such as coughing or choking; (2) symptoms clinically indicative of dysphagia, such as reduced gag reflex or delayed swallowing reflex; and (3) a history of using alternative feeding methods, such as a nasogastric tube. Patients who could not sit or those who had difficulty maintaining consciousness were excluded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eAspiration pneumonia\u003c/h2\u003e\u003cp\u003eA retrospective review was conducted to investigate the development of aspiration pneumonia within 1 month before and after a VFSS in stroke patients with dysphagia.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The following data were collected: symptoms, such as coughing during feeding; the presence of sputum, dyspnea, or fever; chest X-ray findings; blood laboratory findings (white blood cell [WBC] counts, C-reactive protein [CRP] level, and erythrocyte sedimentation rate); and use of antibiotics.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAlthough a definitive diagnosis of aspiration is difficult and the diagnostic criteria for aspiration pneumonia are slightly different across studies, patients who met all of the following criteria were considered to have aspiration pneumonia in the present study: (1) the presence of both objective signs (coarse lung sounds, the presence of lung infiltration on chest X-ray, and systemic inflammation based on blood laboratory findings, such as increased CRP levels and WBC counts) and subjective symptoms (fever, cough, and increased purulent sputum), (2) clinical suspicion of aspiration (delayed swallowing or coughing during swallowing), and (3) no evidence of microorganisms, such as \u003cem\u003eLegionella\u003c/em\u003e or \u003cem\u003eMycoplasma\u003c/em\u003e, which are common pathogens in atypical pneumonia.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] In addition, the clinical reports from the Internal Medicine Department were used to diagnose aspiration pneumonia.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eThe VFSS protocol\u003c/h2\u003e\u003cp\u003eThe VFSS was performed with a fluoroscopic device and recorded as a video file. During the VFSS, patients consecutively swallowed the following materials that had a stepwise consistency: water, nectar (51\u0026ndash;350 cP), rice porridge (351-1,750 cP), and boiled rice (\u0026gt;\u0026thinsp;1,750 cP).[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The materials were mixed with liquid barium, and the patient swallowed them while in a relaxed sitting position. Dynamic fluoroscopic images were obtained in the anterior-posterior and lateral views and were recorded at 30 frames per second. The VFSS images were analyzed according to the Penetration-Aspiration Scale (PAS) and considered positive for aspiration if the PAS score was \u0026gt;\u0026thinsp;5.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAll studies were reviewed by two physiatrists who had at least 7 years of experience in interpreting VFSS results. Patient information, including age, sex, and underlying diseases, was withheld from the interpreters. The interpreters only observed the patients using the movie files on the laptop, described their findings, and chose a feeding method (non-oral feeding versus oral feeding) based on the VFSS results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eModification of the VDS\u003c/h2\u003e\u003cp\u003eThe mVDS was developed based on a study regarding the inter-rater reliability of the VDS.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Among the VDS categories, the ones with a κ value\u0026thinsp;\u0026lt;\u0026thinsp;0.2 (bolus formation, mastication, apraxia, tongue in palate contact, and pharyngeal transit time) were modified. As mentioned by previous researchers, such categories had somewhat ambiguous guidelines and three to four multiple selectable choices, which lead to low reliability.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Therefore, we modified the categories according to a binary scale or deleted the ambiguous categories. The mVDS was drafted as follows (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The bolus formation and tongue to palate contact categories, which had multiple selectable choices, were deleted because of their ambiguous criteria. The lip closure and mastication categories were modified according to a binary scale of intact/not intact. The pharyngeal transit time category was based on a binary scale, but it was deleted because it had a low κ value, as it is thought to have some similarity with triggering of the pharyngeal reflex. The laryngeal elevation category had an ambiguous guideline, and the κ value was low (0.202). We changed the category to laryngeal inversion, which was reported to be an important factor in the swallowing process in a previous study because laryngeal elevation and epiglottis inversion are a result of a combination of contraction/relaxation of the suprahyoid and infrahyoid muscles.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eModified version of the Videofluoroscopic Dysphagia Scale\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eparameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003escore\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003elip closure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eintact / not intact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emassification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epossible / not possible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 11.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eoral transit time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1.5 seconds / \u0026gt;1.5 seconds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003etriggering pharyngeal swallow (swallowing reflex)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eintact / delayed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eepiglottis inversion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyes / no\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003evalleculae residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0% / \u0026lt;10% / \u0026ge;10%, \u0026lt;\u0026thinsp;50% / \u0026ge;50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 3 / 6 / 9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epyriformis residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0% / \u0026lt;10% / \u0026ge;10%, \u0026lt;\u0026thinsp;50% / \u0026ge;50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 6.5 / 13 / 19.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epharyngeal wall coating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eno / yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003easpiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eintact / penetration / aspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 / 8.5 / 17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003etotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOriginally, to measure these VFSS findings as objective quantitative scores, the VDS with a sum of 100 points was created according to the odds ratios of various prognostic factors.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] After modification of the parameters of the VDS, we re-balanced each category\u0026rsquo;s score of the mVDS, which had a sum of 100 points (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe intra-class correlation coefficient (ICC) model 2.1 of the VDS was used to test the inter-rater reliability based on the mVDS scores provided by the interpreters. The ICC model was used because it can be utilized for scale and ordinal variables. Ordinal variables equivalent to the weighted κ/ICC values\u0026thinsp;\u0026gt;\u0026thinsp;0.80 were considered very good, and those with κ/ICC values between 0.60 and 0.80 were considered good.\u003c/p\u003e\u003cp\u003eTo evaluate the correlation between the mVDS and the selected feeding method and between the mVDS and the presence of aspiration pneumonia after stroke, a univariate logistic regression analysis with the enter method was used. To evaluate the accuracy of predictive factors for oral feeding or non-oral feeding based on the VFSS findings, we performed a receiver operating characteristic (ROC) analysis. Statistical analysis was conducted using the MedCalc program (MedCalc Software, Ostend, Belgium) and SPSS software version 22.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":" \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eFifty-six stroke patients with dysphagia were enrolled in this study. Among them, 33 patients were male and 23 were female. Thirty-seven patients had ischemic stroke and 19 had hemorrhagic stroke. Thirty-eight patients had supratentorial stroke and 18 had infratentorial stroke. The patients\u0026rsquo; demographic data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of stroke patients with dysphagia in the present study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003echaracteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (median ; 25% \u0026minus;\u0026thinsp;75%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eage (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.96\u0026thinsp;\u0026plusmn;\u0026thinsp;14.456 (77.00 ; 63.25\u0026ndash;80.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esex (male:female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (58.9%) : 23 (41.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eduration of disease (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e422.64\u0026thinsp;\u0026plusmn;\u0026thinsp;714.519 (255.00 ; 169\u0026ndash;296.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePAS grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.331 (3.00 ; 2.00\u0026ndash;5.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2453\u0026thinsp;\u0026plusmn;\u0026thinsp;10.03629 (17.0000 ; 4.5000\u0026ndash;24.0000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBI score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.6038\u0026thinsp;\u0026plusmn;\u0026thinsp;21.61938 (26.0000 ; 12.0000 \u0026minus;\u0026thinsp;43.0000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esupra/infra-tentorial stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (67.9%) : 18 (32.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emVDS scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elip closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.363 (0.00 ; 0.00\u0026ndash;0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emassification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.107\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5602 (0.000 ; 25% \u0026minus;\u0026thinsp;75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoral transit time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.412 (0.00 ; 0.00\u0026ndash;0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etriggering pharyngeal swallowing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.935 (7.00 ; 7.00\u0026ndash;7.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eepiglottis inversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.434 (0.00 ; 0.00\u0026ndash;0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evalleculae residue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.695 (3.00 ; 3.00\u0026ndash;3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epyriformis residue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.063\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5647 (3.250 ; 0.000\u0026ndash;6.500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epharyngeal wall coating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.212 (0.00 ; 0.00\u0026ndash;0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003easpiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.714\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5698 (8.500 ; 8.500\u0026ndash;17.000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.277\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6411 (32.500 ; 21.500\u0026ndash;48.375)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003ePAS: penetration-aspiration scale, mVDS: modified videofluoroscopic dysphaga scale, MMSE: mini-mental status examination, MBI; modified Bathel Index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInter-rater reliability of the mVDS\u003c/h2\u003e \u003cp\u003eThe inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation between the mVDS and the selected feeding method based on the VFSS findings\u003c/h2\u003e \u003cp\u003eIn all patients, the mVDS score was statistically correlated with the selected feeding method (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the ROC curve analysis, the area under the ROC curve (AUC) for the selected feeding method was 0.904 (95% confidence interval [CI], 0.795\u0026ndash;0.966; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The optimal cut-off value for the allowance of oral feeding obtained from the maximal Youden index was a score of \u0026le;\u0026thinsp;36.5 based on the mVDS (sensitivity, 76.19%; specificity, 92.86%) for the allowance of oral feeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-A). Additionally, a score of \u0026le;\u0026thinsp;32 based on the mVDS showed a sensitivity of 66.67% and specificity of 100% for the allowance of oral feeding. For non-oral feeding, the optimal cut-off value obtained from the maximal Youden index was a score of \u0026ge;\u0026thinsp;36.5 based on the mVDS (sensitivity, 92.86%; specificity, 76.19%). Additionally, a score of \u0026ge;\u0026thinsp;67 showed a sensitivity of 28.57% and specificity of 100% for non-oral feeding.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression analysis (with the enter method) of the association between the modified version of the Videofluoroscopic Dysphagia Scale scores and the selection of the oral feeding method.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeta coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal stroke patients with dysphagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emVDS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003cp\u003e(0.839\u0026ndash;0.949)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with supratentorial stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emVDS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003cp\u003e(0.823\u0026ndash;0.954)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with infratentorial\u003c/p\u003e \u003cp\u003estroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emVDS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003cp\u003e(0.824\u0026ndash;1.020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003emVDS, modified version of the Videofluoroscopic Dysphagia Scale; OR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the subgroup analysis of patients with supratentorial stroke, the mVDS score was also statistically correlated with the selected feeding method (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In the ROC curve analysis, the AUC for the selected feeding method was 0.926 (95% CI, 0.793\u0026ndash;0.986; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The optimal cut-off value obtained from the maximal Youden index was a score of \u0026le;\u0026thinsp;32 based on the mVDS (sensitivity, 74.07%; specificity, 100.0%) for the allowance of oral feeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-B). Additionally, a score of \u0026ge;\u0026thinsp;67 showed a sensitivity of 27.27% and specificity of 100% for non-oral feeding.\u003c/p\u003e \u003cp\u003eIn the subgroup analysis of patients with infratentorial stroke, the mVDS score was also statistically correlated with the selected feeding method (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In ROC curve analysis, the AUC for the selected feeding method was 0.822 (95% CI, 0.573\u0026ndash;0.959; p\u0026thinsp;=\u0026thinsp;0.0067). The optimal cut-off value obtained from the maximal Youden index was a score of \u0026le;\u0026thinsp;34.5 based on the mVDS (sensitivity, 73.33%; specificity, 100.0%) for the allowance of oral feeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-C). Additionally, a score of \u0026ge;\u0026thinsp;51 showed a sensitivity of 33.33% and specificity of 100% for non-oral feeding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation between the mVDS and the development of aspiration pneumonia\u003c/h2\u003e \u003cp\u003eIn the univariate logistic regression analysis, the mVDS score was significantly correlated with the presence of aspiration pneumonia after stroke (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression analysis (with the enter method) of the association between the modified version of the Videofluoroscopic Dysphagia Scale and the development of aspiration pneumonia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeta coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDevelopment of aspiration pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emVDS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.053\u003c/p\u003e \u003cp\u003e(1.012\u0026ndash;1.095)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003emVDS, modified version of the Videofluoroscopic Dysphagia Scale; OR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eIn this study, the mVDS scores showed a statistically significant correlation with the selection of oral feeding in stroke patients with dysphagia. The result of the subgroup analysis, based on the lesion location, was also statistically significant. Interestingly, the analysis of all patients and patients with supratentorial stroke showed that an mVDS score of 32 had a specificity of 100%, whereas the analysis of patients with infratentorial lesions showed that an mVDS score of 34.5 had a specificity of 100%. Therefore, in general, an mVDS score of 32 is the reference point for selecting oral feeding, with a specificity of 100%.\u003c/p\u003e \u003cp\u003eFor non-oral feeding in all stroke patients with dysphagia and in those with supratentorial stroke, an mVDS score of \u0026gt;\u0026thinsp;60 had a specificity of 100%. However, in patients with infratentorial stroke, an mVDS score of \u0026ge;\u0026thinsp;51 or higher had a specificity of 100%. One possible explanation for this discrepancy is the difference in the total number of patients in the two subgroups. The number of patients with infratentorial stroke was smaller than that of patients with infratentorial stroke, and this may have led to the different statistical outcome. Another possible explanation is the aspiration category of the mVDS. The score of the aspiration category of the mVDS does not change in accordance with how often the aspiration was detected during the VFSS. Patients with infratentorial stroke may have shown a higher incidence of aspiration during the VFSS than those with supratentorial stroke;[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] therefore, they may have not been able to feed orally, but it would not have been accounted for in the mVDS score. In other words, the same mVDS score could still mean that the severity of swallowing difficulty may have been more in patients with infratentorial stroke than in those with supratentorial stroke.\u003c/p\u003e \u003cp\u003eAccording to the inter-rater reliability test, the mVDS score showed an ICC of 0.886, which was higher than that of the original VDS score (0.556).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] This may be due to the modification made to the categories that were somewhat ambiguous to score or had multiple choices.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Despite such a modification, the mVDS score was significantly correlated with the selection of oral feeding and development of aspiration pneumonia, which are important diagnosis of VFSS. Considering such correlations, it is possible to assume that the mVDS can sufficiently describe and analyze the VFSS results. However, nine of the 14 categories of the VDS have at least three selectable values, and the distinguishing between them is somewhat ambiguous.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] This may lead to low inter-rater reliability.\u003c/p\u003e \u003cp\u003eIn the mVDS, similar to the VDS, a higher score indicates a greater diet limitation and more severe dysphagia. The mVDS can produce numerical data regarding swallowing function by using comprehensive VFSS findings with a relatively high inter-rater reliability. Therefore, the mVDS provides more intuitive data than conventional VFSS interpretation, which is usually focused on the presence of aspiration or penetration.\u003c/p\u003e \u003cp\u003eThere are several limitations to our study. First, the total number of enrolled patients was relatively small. Therefore, it may be challenging to make a general conclusion. Nonetheless, the result showed consistency in all stroke patients with dysphagia, the supratentorial stroke subgroup, and the infratentorial stroke subgroup. However, further studies with a greater number of participants are needed to make a more generalized conclusion. Second, the study was limited to stroke patients with dysphagia. Considering the application of the VFSS in the broad spectrum of etiology, it is crucial to apply the mVDS to diseases other than stroke.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThe mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies to interpret the VFSS findings in stroke patients with dysphagia. In patients with an mVDS score of \u0026le;\u0026thinsp;32, it should be considered safe to select oral feeding as the feeding method.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgement:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eFinancial Disclosure:\u003c/h2\u003e\n\u003cp\u003eNo commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.\u003c/p\u003e\n\u003ch2\u003eDisclosure:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eConflict of interest:\u003c/h2\u003e\n\u003cp\u003eThe authors report no conflict of interest or financial support.\u003c/p\u003e\n\u003ch2\u003eFunds:\u003c/h2\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003ch2\u003eAuthors contribution:\u003c/h2\u003e\n\u003cp\u003eByung Joo Lee: Writing \u0026ndash; original draft, and Writing \u0026ndash; review and editing\u003c/p\u003e\n\u003cp\u003eHyoshin Eo: Data acquisition, Data curation\u003c/p\u003e\n\u003cp\u003eChangbae Lee: Data acquisition, Data curation\u003c/p\u003e\n\u003cp\u003eDonghwi Park: Conceptualization, Formal analysis, Writing \u0026ndash; original draft, and Writing \u0026ndash; review and editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKarkos PD, Papouliakos S, Karkos CD, Theochari EG. Current evaluation of the dysphagic patient. Hippokratia \u003cstrong\u003e2009\u003c/strong\u003e; 13:141-6.\u003c/li\u003e\n\u003cli\u003eChang MC, Park JS, Lee BJ, Park D. Effectiveness of pharmacologic treatment for dysphagia in Parkinson's disease: a narrative review. Neurol Sci \u003cstrong\u003e2020\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003ePark D, Suh JH, Kim H, Ryu JS. The Effect of Four-Channel Neuromuscular Electrical Stimulation on Swallowing Kinematics and Pressures: A Pilot Study. Am J Phys Med Rehabil \u003cstrong\u003e2019\u003c/strong\u003e; 98:1051-9.\u003c/li\u003e\n\u003cli\u003eCosta MM. Videofluoroscopy: the gold standard exam for studying swallowing and its dysfunction. Arq Gastroenterol \u003cstrong\u003e2010\u003c/strong\u003e; 47:327-8.\u003c/li\u003e\n\u003cli\u003ePark D, Oh Y, Ryu JS. Findings of Abnormal Videofluoroscopic Swallowing Study Identified by High-Resolution Manometry Parameters. Arch Phys Med Rehabil \u003cstrong\u003e2016\u003c/strong\u003e; 97:421-8.\u003c/li\u003e\n\u003cli\u003eSchooling TL. Lessons from the National Outcomes Measurement System (NOMS). Semin Speech Lang \u003cstrong\u003e2003\u003c/strong\u003e; 24:245-56.\u003c/li\u003e\n\u003cli\u003eLee JH, Lee KW, Kim SB, Lee SJ, Chun SM, Jung SM. The Functional Dysphagia Scale Is a Useful Tool for Predicting Aspiration Pneumonia in Patients With Parkinson Disease. Ann Rehabil Med \u003cstrong\u003e2016\u003c/strong\u003e; 40:440-6.\u003c/li\u003e\n\u003cli\u003eKim J, Oh BM, Kim JY, Lee GJ, Lee SA, Han TR. Validation of the videofluoroscopic dysphagia scale in various etiologies. Dysphagia \u003cstrong\u003e2014\u003c/strong\u003e; 29:438-43.\u003c/li\u003e\n\u003cli\u003eMo SJ, Jeong HJ, Han YH, Hwang K, Choi JK. Association of Brain Lesions and Videofluoroscopic Dysphagia Scale Parameters on Patients With Acute Cerebral Infarctions. Ann Rehabil Med \u003cstrong\u003e2018\u003c/strong\u003e; 42:560-8.\u003c/li\u003e\n\u003cli\u003eHan TR, Paik NJ, Park JW. Quantifying swallowing function after stroke: A functional dysphagia scale based on videofluoroscopic studies. Arch Phys Med Rehabil \u003cstrong\u003e2001\u003c/strong\u003e; 82:677-82.\u003c/li\u003e\n\u003cli\u003eKim DH, Choi KH, Kim HM, et al. Inter-rater Reliability of Videofluoroscopic Dysphagia Scale. Ann Rehabil Med \u003cstrong\u003e2012\u003c/strong\u003e; 36:791-6.\u003c/li\u003e\n\u003cli\u003eKim GE, Sung IY, Ko EJ, Choi KH, Kim JS. Comparison of Videofluoroscopic Swallowing Study and Radionuclide Salivagram for Aspiration Pneumonia in Children With Swallowing Difficulty. Ann Rehabil Med \u003cstrong\u003e2018\u003c/strong\u003e; 42:52-8.\u003c/li\u003e\n\u003cli\u003eYu KJ, Moon H, Park D. Different clinical predictors of aspiration pneumonia in dysphagic stroke patients related to stroke lesion: A STROBE-complaint retrospective study. Medicine (Baltimore) \u003cstrong\u003e2018\u003c/strong\u003e; 97:e13968.\u003c/li\u003e\n\u003cli\u003eYu KJ, Park D. Clinical characteristics of dysphagic stroke patients with salivary aspiration: A STROBE-compliant retrospective study. Medicine (Baltimore) \u003cstrong\u003e2019\u003c/strong\u003e; 98:e14977.\u003c/li\u003e\n\u003cli\u003eBorders JC, Brates D. Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review. Dysphagia \u003cstrong\u003e2020\u003c/strong\u003e; 35:583-97.\u003c/li\u003e\n\u003cli\u003eA. Duarte JLdA, \u0026Uacute;. Martins, C. Magro, C. Lima, S. Ara\u0026uacute;jo, N. Pereira, M. Coutinho, H. Marques. Epiglottic kinematics alterations and risk of laryngeal penetration-aspiration. Annals of Physical and Rehabilitation Medicine \u003cstrong\u003e2018\u003c/strong\u003e; 61:e189-e90.\u003c/li\u003e\n\u003cli\u003eKim YK, Cha JH, Lee KY. Comparison of Dysphagia Between Infratentorial and Supratentorial Stroke Patients. Ann Rehabil Med \u003cstrong\u003e2019\u003c/strong\u003e; 43:149-55.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"deglutition, swallowing difficulty, dysphagia, Videofluoroscopic Dysphagia Scale, videofluoroscopic swallowing study, modified version of the Videofluoroscopic Dysphagia Scale","lastPublishedDoi":"10.21203/rs.3.rs-155745/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-155745/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e The Videofluoroscopic Dysphagia Scale (VDS) is used to predict the long-term prognosis of dysphagia in patients with stroke. However, the inter-rater reliability of the VDS was low in a previous study. To overcome the mentioned limitations of the VDS, the modified version of the VDS (mVDS) was created and clinically applied to evaluate its usefulness in choosing the feeding method for stroke patients with dysphagia.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The videofluoroscopic swallowing study (VFSS) data of 56 stroke patients with dysphagia were collected retrospectively. We investigated the presence of aspiration pneumonia and the selected feeding method. We also evaluated the correlations between the mVDS and the selected feeding method, and between the mVDS and the presence of aspiration pneumonia after stroke. Univariate logistic regression and receiver operating characteristic analyses were used in the data analysis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The inter-rater reliability (Cronbach α value) of the total score of the mVDS was 0.886, which was consistent with very good inter-rater reliability. In all patients, the supratentorial stroke subgroup, and the infratentorial stroke subgroup, the mVDS scores were statistically correlated with the feeding method selected (p\u0026lt;0.05) and the presence of aspiration pneumonia (p\u0026lt;0.05).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The mVDS can be a useful scale for quantifying the severity of dysphagia, and it can be a useful tool in the clinical setting and in studies for interpreting the VFSS findings in stroke patients with dysphagia. Further studies with a greater number of patients and various stroke etiologies are required for more generalized application of the mVDS.\u003c/p\u003e","manuscriptTitle":"Usefulness of the Modified Videofluoroscopic Dysphagia Scale in Choosing the Feeding Method for Stroke Patients with Dysphagia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-02-02 20:29:32","doi":"10.21203/rs.3.rs-155745/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae411fd2-3e00-48de-b23c-32102dd351bf","owner":[],"postedDate":"February 2nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":2207478,"name":"Health Economics \u0026 Outcomes Research"},{"id":2207479,"name":"Scientific Communication"}],"tags":[],"updatedAt":"2024-07-13T11:52:52+00:00","versionOfRecord":{"articleIdentity":"rs-155745","link":"https://doi.org/10.3390/healthcare9060632","journal":{"identity":"healthcare","isVorOnly":true,"title":"Healthcare"},"publishedOn":"2021-05-27 11:52:52","publishedOnDateReadable":"May 27th, 2021"},"versionCreatedAt":"2021-02-02 20:29:32","video":"","vorDoi":"10.3390/healthcare9060632","vorDoiUrl":"https://doi.org/10.3390/healthcare9060632","workflowStages":[]},"version":"v1","identity":"rs-155745","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-155745","identity":"rs-155745","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}