Dysphagia 13:32–38 (1998)
© Springer-Verlag New York Inc. 1998
Dysphagia in Stroke: A Prospective Study of Quantitative Aspects of
Swallowing in Dysphagic Patients
Håkan Nilsson, MD,1 Olle Ekberg, MD, PhD,2 Rolf Olsson, MD, PhD,2 Bengt Hindfelt, MD, PhD1
Departments of 1Neurology and 2Diagnostic Radiology, University of Lund, Malmö University Hospital, Malmö, Sweden
Abstract. This is a prospective study of 100 consecutive
stroke patients. Within 24 h after stroke onset they were
asked specifically about swallowing complaints and sub-
jected to a clinical examination including neurologic ex-
amination, Mini-Mental test, and Barthel score. Dys-
phagic patients were examined with the repetitive oral
suction swallow test (the ROSS test) for quantitative
evaluation of oral and pharyngeal function at 24 h, after
1 week, and after 1 month. At 6 months, the patients
were interviewed about persistent dysphagia. Seventy-
two patients could respond reliably at 24 h after the
stroke onset and 14 of these complained of dysphagia.
Non-evaluable patients were either unconscious, aphasic,
or demented. The presence of dysphagia was not influ-
enced by age or other risk factors for stroke. Facial pa-
resis, but no other clinical findings, were associated with
dysphagia. Dysphagia 24 h after stroke increased the risk
of pneumonia but did not influence the length of hospital
stay, the manner of discharge from hospital, or the mor-
tality. The initial ROSS test, during which the seated
patient ingests water through a straw, was abnormal in all
dysphagic stroke patients. One-third of the patients were
unable to perform the test completely. Above all, dys-
function was disclosed during forced, repetitive swallow.
All phases of the ingestion cycle were prolonged
whereas the suction pressures, bolus volumes, and swal-
lowing capacities were low. Abnormalities of quantita-
tive swallowing variables decreased with time whereas
the prevalences of swallowing incoordination and abnor-
mal feeding-respiratory pattern became more frequent.
After 6 months, 7 patients had persistent dysphagia. Five
of these were initially non-evaluable because of uncon-
sciousness, aphasia, or dementia.
Key words: Deglutition disorders — Dysphagia —
Correspondence to: Håkan Nilsson, M.D., Department of Medicine,
Vrinnevi Hospital, S-601 82 Norrköping, Sweden
Stroke — Prospective study — Quantitative test — De-
glutition.
Dysphagia is common in various neurologic disorders,
and particularly in stroke [1–5]. Although swallowing
dysfunction may have prognostic consequences [1,2,6],
there are few longitudinal studies of dysphagia or swal-
lowing dysfunction in stroke [2,5,7]. This study was un-
dertaken with the limited scope of evaluating the preva-
lence of symptomatic swallowing dysfunction in the
acute stage of stroke and to correlate dysphagia with
major neurologic deficits. Furthermore, in the stroke pa-
tients complaining of dysphagia, the oral and pharyngeal
swallow were quantitatively assessed. These patients
were also followed up prospectively by repeated quanti-
tative assessments.
Materials and Methods
The study participants included 100 consecutive patients (40 females,
60 males), median age 77 yr (range 59–94 yr) with acute ischemic or
hemorrhagic strokes admitted to the stroke unit at the Department of
Internal Medicine in Norrköping. A total of 61 patients underwent a
neuroradiologic examination [59 were examined by computerized to-
mography (CT) and 2 by magnetic resonance imaging (MRI)]. All
patients were asked about swallowing complaints within 24 hr after
stroke onset by HN. Patients were considered dysphagic if they re-
ported one or several of the following: (1) they could not eat or drink
normally, (2) food got stuck in their mouth or throat, (3) they coughed
during or after swallowing.
Neurologic examination was performed by a senior neurologist.
Cognitive function was tested by the Mini-Mental test [8]. The severity
of the handicap was estimated according to the Barthel Index (the 20
graded scale) [9] at days 1 and 7 after the stroke. Intravenous drip was
given but no patient had a nasogastric tube inserted, nor a gastrostomy.
The food consistency was adjusted by a skilled nurse as needed for the
dysphagic patients. Commonly, purée was recommended for patients
with oral dysfunction and thickened liquid patients prone to aspiration.
No particular swallowing rehabilitation was performed.
H. Nilsson et al.: Dysphagia in Stroke
The stroke patients, who on admission complained of dyspha-
gia, were examined by the ROSS test, during which the seated patient
was instructed to drink 200 ml of water through a straw, previously
described in detail [10]. Assessment was performed during single swal-
low and forced, repetitive swallow (‘‘stressed swallow’’) with record-
ings of the weight of water remaining in the glass, the suction pressure,
the signals from a Doppler probe, and a piezo-electric movement sensor
applied to the neck and a thermodetector in the nostril. The peak
suction pressure, time of suction, bolus volume, time from suction to
swallowing, swallowing capacity, and time for a completed ingestion
cycle were recorded. Furthermore, the interactions among suction,
swallowing, and respiration were assessed.
The ROSS test was performed on three occasions: within 24 hr,
1 week (range 6–8 days), and 1 month (range 24–41 days) after the
stroke. Furthermore, after 6 months the patients were interviewed about
any persistent swallowing complaints. The results were compared with
the findings in a reference group consisting of 53 elderly nondysphagic
subjects (31 females, 22 males, age >70 years, mean age 76 ± 5 yr) in
a previous study published in Dysphagia [11].
Statistical Methods
Values were expressed as median values and interquartile ranges. For
statistical analysis, the Spearman test, the Kruskal-Wallis test, and the
Mann-Whitney U-test were used. The Chi-2 test with Yates correction
was applied for analysis of frequencies. A p value <0.05 was consid-
ered significant. Values were considered abnormal if above 97.5% or
below 2.5% of the nonparametric normal range of the control group.
Results
Of the one hundred stroke patients, only 72 were able to
reliably answer the questions asked (see Methods). Four-
teen patients complained of dysphagia and 58 patients
did not. None of these dysphagic patients needed paren-
teral nutrition. Twenty-eight patients could not be evalu-
ated at 24 h after the stroke because of either uncon-
sciousness (n 4 14, 8 females), aphasia (n 4 9, 5 fe-
males), or dementia (n 4 5, 3 females) that had
developed during the acute stroke. Most unconscious pa-
tients had intravenous drip. No patients had a nasogastric
tube.
Ninety-five patients suffered from cerebral hemi-
spheric stroke diagnosed clinically and frequently con-
firmed by CT (n 4 59) or MRI (n 4 2) examinations.
Forty-six patients had left-sided pareses, 38 had right-
sided pareses, and 11 were aphasic or had cognitive im-
pairments. Five patients had brainstem strokes (Table 1).
Of the various neurologic deficits evaluated, only
central facial paresis was significantly more prevalent
among the dysphagic patients [11/14 (79%) vs. 22/58
(38%) in the nondysphagic patients; p < 0.05]. In those
patients who could respond to the initial interview, the
clinical deficits did not differ significantly between the
dysphagic and nondysphagic patients (Table 1).
Risk factors for stroke such as male gender, hy-
33
pertension, previous stroke, diabetes mellitus, smoking,
atrial fibrillation, and other cardiac disease (angina pec-
toris, myocardial insufficiency, status postmyocardial in-
farction, or valvular disorders) did not differ between the
dysphagic and nondysphagic patients (Table 1).
Quantitative Assessment of Swallowing
First Examination Within 24 h after Stroke. The
ROSS test was performed in all dysphagic patients ex-
cept 2 because of technical problems. Quantitative as-
sessment of single swallow was frequently normal at 24
hr after the stroke. Of the measured parameters, only
suction time and oral pharyngeal transit time were sta-
tistically significantly prolonged (Table 2). However,
during forced, repetitive swallow suction time, oral pha-
ryngeal transit time, feeding interval, and ingestion cycle
time were significantly prolonged and the bolus volume
and swallowing capacity were significantly lower com-
pared with the reference group (Table 2).
Second Examination after 1 Week. During single
swallow, suction time and oral pharyngeal transit time
were still significantly abnormal. During forced, repeti-
tive swallow, the bolus volume was now normal. Suction
time, oral pharyngeal transit time, feeding interval and
ingestion cycle time were still significantly abnormal.
The swallowing capacity had improved but was still be-
low normal (Table 2).
Third Examination after 1 Month. During single
swallow, all parameters had improved (Table 2). Suction
pressure was now even above the normal range. The
suction time was still prolonged whereas all other pa-
rameters had normalized. Also during forced repetitive
swallow, abnormally high suction pressure was seen.
The bolus volume was normal but the suction time, oral
pharyngeal transit time, feeding interval, and ingestion
cycle time were still significantly prolonged. The swal-
lowing capacity was about twice the value in the first
examination but still below that of the reference group
(Table 2).
During analysis of frequencies, all patients had at
least one abnormal variable in the ROSS test performed
within 24 h (Table 3). On reexamination, 1 week after
stroke onset 2 patients had normal results and when ex-
amined 1 month after the stroke, all patients had im-
proved. Three of 4 patients who initially could not per-
form the ROSS test could now be examined. Six out of
7 patients had ceased coughing while eating or drinking.
Despite complaints of dysphagia and coughing dimin-
ished with time, the ROSS test revealed several abnormal
findings in 10 (83%) patients (Table 3). The most fre-
quent abnormal findings were polyphasic laryngeal
movements, seen in 8 (67%) patients compared with 4
34 H. Nilsson et al.: Dysphagia in Stroke

Table 1. Clinical and prognostic findings in 100 consecutive acute stroke patientsa

p value
Dysphagic Nondysphagic Non-evaluable (Kruskal-
patients patients patients Wallis
n 4 14 n 4 58 n 4 28 test)

Predisposing factors for stroke

Age (yr)b 76 ± 6 73 ± 11** 80 ± 7 0.017
Male gender 7 (50%) 17 (29%) 12 (43%) NS
Previous stroke 4 (29%) 12 (21%) 6 (21%) NS
Hypertension 7 (50%) 22 (38%) 14 (50%) NS
Atrial fibrillation 3 (21%) 11 (19%) 9 (32%) NS
Other cardiac disorder 3 (21%) 18 (31%) 11 (39%) NS
Diabetes mellitus 3 (21%) 10 (17%) 4 (14%) NS
Current smoker 1 (7%) 7 (12%) 2 (7%) NS
Any risk factor 12 (86%) 46 (79%) 23 (82%) NS
Stroke location and clinical signs
Hemispheric strokes
Left-sided pareses 5 (36%) 29 (50%) 12 (43%) NS
Right-sided pareses 6 (43%) 19 (33%) 13 (46%) NS
No pareses 2 (14%) 8 (14%) 1 (4%) NS
Brainstem strokes 1 (7%) 2 (3%) 2 (7%) NS
Facial paresis 11 (79%)# 22 (38%) 20 (71%)## 0.0018
Outcome
Barthel Index day 1b 8.8 ± 8.0*** 9.9 ± 8.4*** 2.2 ± 4.8 0.001
Barthel Index day 7b 10.8 ± 7.8* 10.2 ± 7.8** 5.6 ± 8.2 0.013
Pneumonia 2 (14%)# 0 3 (11%) 0.024
Days in hospitalc 14 (8–47) 10 (6–22) 16 (7–27) NS
Way of discharge
Returned home 10 (71%)* 46 (79%)*** 8 (29%) <0.001
Nursing home, etc. 4 (9%) 11 (19%) 6 (21%) NS
Death 0** 1 (2%)*** 14 (50%) <0.001
a
The patients were separated in dysphagic patients, nondysphagic patients, and non-evaluable patients at 24 h after the stroke onset.
b
Mean ± SD. cMedian value (interquartile range).
*p < 0.05; **p < 0.01; ***p < 0.001 vs. non-evaluable patients.
†p < 0.05; #p < 0.01 vs. nondysphagic patients.

(33%) patients on the first examination. Respiration dur-
ing swallowing was seen in 8 (67%) patients compared
with 5 (42%) patients on the first examination. Prolonged
feeding interval and decreased swallowing capacity were
also frequent.
The whole group of patients spent a median time
of 13 days (6–28 days) in the acute ward and rehabilita-
tion unit combined. The time spent in hospital did not
correlate with age, and no significant differences were
found between the nonevaluable patients and patients
with and without dysphagia (Table 1). The Barthel index
at day 1 correlated with the time spent in the hospital (rs
4 −0.53, p < 0.001) and with age (rs 4 −0.23, p < 0.05).
The Barthel Index was significantly lower in the non-
evaluable patients but did not differ between the dys-
phagic and nondysphagic patients. There was a low in-
cidence of pneumonia in all groups of patients, though
significantly more frequent in dysphagic patients com-
pared with nondysphagic patients [2/14 (14%) dysphagic
patients, 0/58 nondysphagic patients, p < 0.05].
Early outcomes were significantly poorer for the
non-evaluable patients compared with the other groups
(Table 1), but similar in dysphagic and nondysphagic
patients. Sixty-four patients returned home. Twenty-one
patients were discharged to nursing homes or other com-
munity-based facilities, and 15 patients died during their
stay in the hospital. Most unconscious patients died with-
out regaining consciousness. No patient died from chok-
ing.
Follow-Up after 6 Months. Six months after the
stroke, the dysphagic patients were interviewed about
swallowing complaints. At this time, 1 patient had died
from renal cancer and 2 of 13 patients had persistent
swallowing complaints.
Among the non-evaluable patients, 18 of 28
(64%) had died—12 of 14 primarily unconscious pa-
tients, 2 of 9 aphasic patients, and 4 of 5 demented pa-
tients. Ten patients were still alive and were interviewed
about swallowing complaints. However, because of per-
sistent aphasia or severe cognitive deficits, the questions
were sometimes answered by relatives or caregivers.
H. Nilsson et al.: Dysphagia in Stroke 35

Table 2. Swallowing in dysphagic acute stroke patients

Examinations

1 2 3 Reference values

Single swallow
Suction pressure (mmHg) 83 (23–145) 89 (23–145) 124 (107–164)** 78 (65–105)
Bolus volume (ml) 20 (4–36) 19 (6–32) 29 (17–36) 23 (20–26)
Suction time (secs) 1.72 (1.59–6.23)*** 1.71 (1.35–2.45)** 1.55 (1.36–1.76)** 1.11 (0.52–1.39)
Oral pharyngeal transit time (secs) 1.25 (0.43–6.05)* 0.80 (0.61–1.42)** 0.64 (0.48–1.02) 0.55 (0.30–0.73)
Time to respiration (secs) 1.38 (0.59–6.15) 0.83 (0.34–1.63) 0.48 (0.02–0.94) 0.71 (0.25–0.98)
Forced, repetitive swallow
Suction pressure (mmHg) 74 (0–172) 147 (0–213) 153 (103–233)* 97 (85–127)
Bolus volume (ml) 9 (0–15)* 15 (0–20) 17 (12–20) 18 (15–21)
Suction time (secs) 2.81 (0.63–NA)* 0.93 (0.76–NA)** 0.86 (0.67–1.05)* 0.71 (0.52–0.85)
Oral pharyngeal transit time (secs) 2.15 (0.30–NA)*** 0.32 (0.22–NA)** 0.45 (0.23–0.96)** 0.19 (0.12–0.37)
Feeding interval (secs) 1.29 (0.51–NA)*** 1.18 (0.36–NA)*** 0.86 (0.45–1.00)*** 0.27 (0.19–0.33)
Ingestion cycle time (secs) 4.77 (1.38–NA)*** 2.79 (1.30–NA)*** 2.06 (1.25–3.36)** 1.26 (0.92–1.48)
Swallowing capacity (ml/sec) 4.3 (0–9.8)*** 5.8 (0–14.7)** 9.1 (4.2–16.5)* 14.8 (13.0–17.1)

Twelve patients [5 females, age 77 (70–81) yrs] were examined on three occasions, within 24 h (examination 1), after 1 week (examination 2), and
after 1 month (examination 3). Reference values in 53 elderly non-dysphagic subjects (see methods).
Values are expressed by median and interquartile range.
NA 4 not assessable.
*p < 0.05; **p < 0.01; ***p < 0.001 compared with the reference value.

Among these 10 patients, 5 were dysphagic (all but 5
initially aphasic patients). No patient had a nasogastric
tube, a gastrostomy, or parenteral nutrition at this time.
Discussion
Dysphagia is defined as ‘‘difficulty in swallowing’’ [12].
In this study, the patient’s estimation of his or her ability
to swallow was the single criterion for separating dys-
phagic from nondysphagic patients. Such self-estimation
is unreliable and certainly does not exclude swallowing
dysfunction, as indicated by various other measures
[13,14]. In this study, only 14 of 72 (19%) patients com-
plained of dysphagia. This is half the figure reported in
previous studies on quantitative swallowing in stroke pa-
tients [1,2,4,5] and underlines the fact that swallowing
dysfunction is frequently subclinical [14].
In this study, more than two-thirds of the patients
suffered their first symptomatic stroke. This was equally
common among the dysphagic and nondysphagic pa-
tients. It has been stated that a unilateral cerebral lesion
may be associated with dysphagia [15]. In dysphagic
stroke patients, computerized tomography of the brain
frequently shows unilateral lesions [16–19]. However,
by the more sensitive MRI, lesions in the nonsymptom-
atic hemisphere may frequently be revealed [18,20–22].
Consequently, the issue about the locations of lesions
that may cause dysphagia is still unsettled [17–20,23].
As the number of patients examined by MRI were few,
we cannot add any evidence on this particular point.
With respect to major neurologic symptoms and
signs, neither hemiparesis nor the affected side correlated
with subjective dysphagia, as previously reported [7,24]
(Table 1). However, a central facial paresis was signifi-
cantly correlated with dysphagia, confirming the findings
in previous studies [2,7] (Table 1). The impact of a facial
paresis on the ability to perform the ROSS test has not
been specifically addressed in earlier studies. It may be
argued that the deviations in the ROSS tests may primar-
ily be due to a facial paresis. However, if facial paresis
was the crucial determinator for the outcome of the
ROSS test results, this should primarily have influenced
the oral function, providing low suction pressures and
low bolus volumes. On the contrary, the bolus volumes
were normal in most examinations. Furthermore, the suc-
tion pressures were initially within normal limits and
later increased to even supranormal levels. Conse-
quently, a facial paresis cannot be considered of major
importance for the results in the test.
Dysphagia with frequent aspiration is associated
with increased risk for subsequent pneumonia [6,7,25,
26]. However, in this study, the frequency of pneumonia
was low, possibly reflecting the fact that most patients
suffered minor strokes, indicated by the short stay in the
hospital, and that no patient needed a nasogastric tube.
The presence of dysphagia did not correlate with
the Barthel indices at days 1 or 7, the length of stay in the
hospital, or the final outcome (Table 1). Numerous pre-
vious studies have shown divergent results with respect
to these variables. Dysphagia after stroke has been asso-
ciated with lower Barthel indices [3,5,7,27], a longer stay
36
Table 3. The frequency of abnormal swallowing in the ROSS test
Examinations
1 2
Single swallow
Low suction pressure (<35 mmHg) 3 3
High suction pressure (>145 mmHg) 3 3
Low bolus volume (<9.0 ml) 5 4
Prolonged suction time (>2.5 sec) 3 3
Prolonged oral pharyngeal transit time (>1.5 sec) 4 2
Abnormal time to respiration (not measurable
or >2.4 sec) 3 2
Forced, repetitive swallow
Inability to perform the test 4 3
Low suction pressure (<42 mmHg) 5 4
High suction pressure (>243 mmHg) 1 2
Low bolus volume (<9.3 ml) 7 5
Prolonged suction time (<1.5 sec) 6 4
Prolonged oral pharyngeal transit time (>0.5 sec) 9 5
Prolonged ingestion cycle time (>2.6 sec) 7 6
Prolonged feeding interval (>0.8 sec) 6 8
Low swallowing capacity (<7.6 ml/sec) 7 7
Coughing (9% in the reference group) 7 5
Polyphasic laryngeal movements (34% in the
reference group) 4 5
Respiration during swallowing (28% in the
reference group) 5 6
Normal examination 0 2
Twelve dysphagic patients with acute stroke were examined on three
occasions; within 24 h (examination 1), after 1 week (examination 2),
and after 1 month (examination 3) after the stroke onset.
in the hospital [27,28], a lower long-term functional abil-
ity [2], and increased risk of death [1,6]. The discrepan-
cies in results are probably explained by variable exclu-
sion and inclusion criteria. When dysphagia is accompa-
nied by decreased wakefulness or dementia, these factors
have to be taken into consideration when analyzing a
possible correlation between dysphagia and the general
outcome. In a previous multivariate analysis of 15 pos-
sible predictors of death and dependence at 3 months
after stroke, swallowing disturbances were found to be
unimportant [29].
The outcome may also be assessed by measuring
the frequency of referrals to nursing homes or other com-
munity-based facilities after the hospital stay. However,
such referrals are substantially influenced by social en-
vironment and other factors not directly associated with
the stroke lesion in itself.
The quantitative data on swallowing should be
interpreted with some caution as no matched control
group of nondysphagic patients was included, nor a con-
trol group of healthy elderly subjects truly matched with
respect to age, gender, or medication. Instead, the com-
parisons were made, regarding an elderly reference
group [11], on the age of the dysphagic stroke patients.
However, the lack of a control group should not invali-
H. Nilsson et al.: Dysphagia in Stroke
date the quantitative data, as the important issue is the
improvement over time, in which case the patients are
their own controls.
3 The suction time and the oral pharyngeal transit
time were prolonged during single swallow, whereas
0 other parameters were initially normal (Table 2). The
3 suction time was prolonged without an increase in bolus
0 volume, indicating oral incoordination or weakness. The
0 oral pharyngeal transit time reflects the pharyngeal tran-
0
sit of bolus, i.e., probably one of the most fundamental
1 variables for describing a safe swallow [30]. After 1
month, the suction time was still prolonged and the suc-
1 tion pressure had increased to supranormal levels, pos-
1
2
sibly as a means of compensation [31]. The oral pharyn-
1 geal transit time normalized with time.
1 More profoundly, abnormal results were seen
5 during forced repetitive swallow. The median suction
4
pressure was normal at 24 h after the stroke despite the
6
6 fact that several patients could not generate the suction
1 pressure needed during this type of swallowing. The me-
dian suction pressure increased to supranormal levels at
8 the 1 month examination in the same way as during
8
single swallow. It should be noted that we measured peak
2 suction pressure and not the area under the pressure
curve. The bolus volume was about half of the reference
value initially but normalized thereafter. All other quan-
titative parameters were abnormal when examined
within 24 h after the stroke and remained so at 1 month,
though there were definite trends towards normalization.
Forced, repetitive swallow (stressed swallowing)
showed more pronounced and persistent deviations than
was seen during single swallow (Table 2). Thus, the
forced, repetitive swallow seems to increase the sensi-
tivity of detecting swallowing dysfunction in stroke pa-
tients. It may be argued that forced, repetitive swallow is
not a physiologic way of swallowing. However, as there
are numerous stressing factors in ‘‘normal’’ swallowing
such as surrounding noise, people talking, time scarcity,
this way of testing may not be ‘‘nonphysiological.’’ The
optimal feeding situation is rare for most patients, and
‘‘stressing’’ factors have to be considered and dealt with
during a meal.
The results in the ROSS test revealed that pha-
ryngeal functions (coughing, polyphasic laryngeal move-
ments, respiration during swallowing, and increased oral
pharyngeal transit time) were more disturbed than oral
functions (suction pressure, bolus volume, multiple swal-
lows to clear the oral cavity) in the initial examination
(Table 2). This probably indicates differences in the in-
nervation complexity of the oral and pharyngeal cavities
by central nervous structures. Most quantitative swallow-
ing parameters improved with time. However, some
swallowing abnormalities, such as polyphasic laryngeal
H. Nilsson et al.: Dysphagia in Stroke
movements, became more frequent (Table 3). Respira-
tion during forced, repetitive swallow also increased, in-
dicating a decreased ability to suppress the respiratory
drive during swallowing. These observations may indi-
cate a defect in the temporal activation of the swallowing
center in the brainstem, normally controlled by higher
cerebral centers.
What is the clinical usefulness of the ROSS test?
It has been questioned if nonradiologic and nonendo-
scopic swallowing tests are sensitive enough and reliable
for assessing dysphagia in stroke patients [3,32,33].
Splaingard et al [32] found that such examination could
identify aspiration in less than half of the videoradio-
graphically aspirating patients. However, 88% of their
patients were abnormal when fed food of various con-
sistencies. In studies applying water swallowing tests,
80% of aspirating patients were identified [3] and pneu-
monia was predicted in 11 of 12 patients [33]. In the
present study, all dysphagic patients had one or more
abnormal ROSS test results when examined within 24 h
after the stroke (Table 3). Although we are well aware of
the fact that our nondysphagic patients were not exam-
ined by the ROSS test, we think that this test may be a
useful screening procedure for revealing an abnormal
swallow, and for providing follow-up data.
At the follow-up after 6 months, 7 of 100 patients
had persistent dysphagia. Previous studies on stroke pa-
tients have shown a prevalence of dysphagia of less than
2% 6 months after stroke [2,5]. Dysphagia at 6 months
after stroke was associated more frequently among pa-
tients with early unconsciousness, dementia, or aphasia.
Only 2 of the 72 patients (3%) who initially could be
evaluated suffered from dysphagia at 6 months. How-
ever, the presence of dysphagia in initially non-evaluable
patients as mostly assessed by their relatives or caregiv-
ers at the 6 months interview which may have influenced
the prevalence of dysphagia in this group. Furthermore,
dysphagia after 6 months may be due to some disease
other than the initial stroke such as hiatal hernia, esoph-
agitis, or recurrent ‘‘subclinical’’ strokes. Thus, the
prevalence of dysphagia found in our patients should be
seen as a maximal value for the incidence.
Our findings indicate that the spontaneous recov-
ery of dysphagia is considerable without swallowing re-
habilitation. As spontaneous improvement of swallowing
after stroke frequently occurs, this has implications for
future studies evaluating therapeutic interventions. In
such studies a randomized control group of patients not
receiving swallowing therapy needs to be included.
Acknowledgments. This study has been supported by grants from the
1987 Foundation for stroke research, the Elsa Schmitz Foundation, and
from Malmö General Hospital Foundation.
37
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