Validation of the Munich Swallowing Score (MUCSS) in patients with neurogenic dysphagia: A preliminary study

Abstract

BACKGROUND:

The Munich Swallowing Score (MUCSS) is a clinician rated scale for the assessment of the functional level of swallowing saliva/secretions, food and liquids. The MUCSS consists of two eight-point subscales, MUCSS-Saliva and MUCSS-Nutrition. In a previous article, content validity and interrater reliability were described.

OBJECTIVE:

The aim of the present study was to investigate criterion validity and sensitivity to change of the MUCSS.

METHODS:

The research was conducted at a tertiary care academic hospital. Data were collected retrospectively in a cohort of 100 acute and subacute neurologic patients. Criterion validity was judged by comparison to the Gugging Swallowing Screen (GUSS), the Barthel Index (BI), Early Rehabilitation Barthel Index (ERI), Extended Barthel Index (EBI) and also by comparison to three physiological scales drawn from FEES videos: The Penetration - Aspiration Scale (PAS), the Yale Pharyngeal Residue Severity Rating Scale (YPR) and the Murray Secretion Scale (MSS). Changes in oral intake and saliva swallowing were followed up for three months.

RESULTS:

Between MUCSS and scores directly reflecting dysphagic symptoms (GUSS, PAS, YPR, MSS, ERI), strong to moderate correlations were found, weaker but statistically significant associations were seen with global measures of disability (BI isolated, EBI-subscale cognitive functions). MUCSS was sensitive to positive change of saliva swallowing and oral intake during the recovery period.

CONCLUSIONS:

These preliminary data suggest that the MUCCS is a valid scale and may be appropriate for documenting clinical change in swallowing abilities of patients with neurogenic dysphagia.

Keywords

Neurogenic dysphagia clinical swallowing rating scale swallowing rehabilitation

1 Introduction

Swallowing disorders represent a complex neurologic condition and have different impacts on the health of an individual. Considering the rehabilitation management as a top-down-process, dysphagia severity measures address different domains. Usually at the beginning of dysphagia rehabilitation, diagnostic procedures assess signs of abnormal swallowing and their underlying pathomechanism. Severity ratings are therefore concentrated on swallowing deficits. These diagnostic results are the prerequisite of the treatment planning, with the main goal of safe and efficient oral feeding and/or successfully swallowing saliva/secretion. Therefore, an assessment of severity is required that describes the functional level of a patient’s eating ability, including the need of non-oral supplementation, dietary restrictions, compensatory strategies and/or the level of saliva/secretion management. In the further process, especially during the chronic phase, questions about the swallowing-related quality of life become increasingly important for the patient. To measure change in this domain, swallowing-specific quality of life questionnaires have been developed. In regard to the guidelines of the ICF-based rehabilitation (International Classification of Functioning, Disability and Health of the world health organisation WHO) (WHO, 2001), the pathophysiological features are allocated to body functions and body structures, whereas the functional swallowing abilities are related to activity. Additionally, scales about the quality of life provide information about participation and wellbeing.

Persistent deficits of eating and drinking can profoundly impact upon an individual’s health, psychosocial wellbeing and quality of life (QOL). Difficulties in saliva/secretion swallowing may enhance the devastating effects. Patients with severe dysfunctions of saliva/secretion swallowing need a cuffed tracheostomy tube to reduce the risk of aspiration. Besides its influence on basic human needs such as respiration and communication adverse psychosocial impacts may arise due to the disfigurement accompanying a tracheostomy. Other mostly negative experiences or potential complications may be related to the management of a tracheostomy. Even patients with mild difficulties in saliva/secretion swallowing who do not need a tube but manage the secretion accumulation by frequent expectoration are socially stigmatized. The main treatment goals during the rehabilitation period of dysphagic patients are regaining full oral intake and/or normal saliva/secretion swallowing. There is a need of appropriate tools to clinically document the status of non-oral/oral nutrition and the handling of saliva/secretion. For patients with severe impairment of swallowing food and liquids, non-oral feeding is essential to prevent aspiration and ensure adequate nutritional intake. The functional levels of non-oral/oral nutrition may be assessed by items that relate to varying degrees of non-oral feeding and to oral intake considering the use of swallowing techniques and/or special food adaptions. Items representing the patient’s progress in swallowing saliva/secretion may include a stepwise approach from initial cuff deflation, tracheostomy tube change, initiation of tube occlusion trials and decannulation to less frequent expectoration of saliva/secretion. The scoring represents the functional dimension of swallowing disorders and refer to the ICF domain activity. Both aspects, oral intake and saliva/secretion swallowing play a crucial role in dysphagia treatment and may require different management strategies. The effects of bolus characteristics on neuromuscular deglutition patterns are documented in many studies. Also differences in brain activation patterns underlying diverse swallowing tasks have been revealed, even between saliva and water swallowing. A meta-analysis of functional brain imaging studies of swallowing indicates, that partly overlapping but clearly distinct neural networks are involved in the central control of voluntarily water and voluntarily saliva swallowing (Sörös et al., 2008). In a study using near-infrared spectroscopy Kober and Wood (2018) observed differences in the cortical topographical distribution and time course of hemodynamic response between water and saliva swallowing. In a retrospective FEES-study Ledl and Mertl-Roetzer (2017) documented, that many patients who aspirated saliva were able to swallow other consistencies safely. Therefore, to cover the different functional levels of saliva/secretion swallowing as completely as possible a separate grading is required.

To date, there are to our knowledge no clinical scales for evaluating both categories accurately. A variety of swallowing scales are available that cover the functional impact of oropharyngeal dysphagia and meet psychometric requirements (reliability and/or validity). Most of the scales comprise different aspects of swallowing impairment, but the handling of oropharyngeal secretions hardly receives any attention. The 7-level Functional Outcome Assessment of Swallowing (FOAMS) (Easterling & Grande, 1999; Okumura et al., 2016) grades the ability of oral intake, but also considers single items regarding supervision and duration of the meals. The Dysphagia Outcome and Severity Scale (DOSS) (O’Neil et al., 1999; Zardaka & Regan, 2018) is also a 7-level scale for rating functional swallowing severity. It covers nutrition type, dietary adaption and independence level. The recently validated Dysphagia Severity Rating Scale (DSRS) was developed from the DOSS and quantifies the modification of fluid and diet intake as well as the supervision level. The scale comprises 3 subscales, each ranging from 0 to 4 points, and their results are added to yield a composite score (Everton et al., 2020). The ASHA NOMS swallowing scale (National Outcome Measurement System of the American Speech-Language-Hearing-Association) (Dungan et al., 2019) also evaluates diet level and supervision. The 7-stage Dysphagia Severity Scale (DSS) (Nishimura et al., 2015) combines suggestions for diet recommendation and treatment, based on clinical signs of dysphagia. The score does indeed include saliva aspiration as the most severe impairment in level 1, but the other 6 levels exclusively assess the ability of nutrition intake. The severity classification of the Functional Outcome Swallowing Scale (FOSS) (Salassa et al., 2000) integrates different categories within 6 severity levels and constitutes an overall functional scale. The swallowing scale of the Australian Therapy Outcome Measures (AusTOMs) (Perry et al., 2004) consists of 4 domains, that are related to the components of the ICF model. A 5-level scale is used within each domain. The often-cited Functional Oral Intake Scale (FOIS) (Crary et al., 2005) describes the amount and type of diet intake in a 7-point scale.

Furthermore, some scales were developed for specific diseases, for example the Dysphagia Management Staging Scale (DMSS) (Sheppard et al., 2014) for children and adults with developmental disabilities. This scale is a multidimensional construct for the rating of feeding and swallowing disorders on a 5-level scale. The Neuromuscular Disease Swallowing Status Scale (NdSS) (Wada et al., 2015) has been developed for patients suffering from neuromuscular disorders. The 8-stage scale primarily refers to oral intake, whereby only level 1 and 2 consider the swallowing of saliva.

Two scales published in German language are worth mentioning, i.e., the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and the Schluckbeeinträchtigungsskala (SBS) (scale of functional swallowing impairments). FEDSS was designed for the fiberoptic endoscopic evaluation of swallowing (FEES) and validated regarding reliability and prediction (Dziewas et al., 2008; Warnecke et al., 2009). A 6-stage score grades dysphagia according to the risks of penetration/aspiration of different food consistencies. The handling of secretions is considered in level 1. The 7-stage SBS (Prosiegel et al., 2002) is based on clinical questions that reflects the functional oral intake, but it has not been tested for its psychometric properties (Prosiegel & Weber, 2018).

Though there is a variety of scales measuring the functional level of oral intake of food and liquid in dysphagic patients, to the best of our knowledge, the varying degrees of saliva/secretion swallowing are scarcely considered to date. The Munich Swallowing Score (MUCSS; Appendix) presented here, aims to fill this gap. In a first pilot study the content validity and interrater reliability were evaluated and published in German language under the name Bogenhausener Dysphagiescore (BODS-1 Saliva/secretion swallowing, BODS-2 oral food intake (Starrost et al., 2012). Content validity was assessed by a mail-out survey. 136 experts in dysphagia treatment were asked to evaluate the former 6-stage version of the BODS on a 5-stage rating scale regarding the following quality criteria: relevance, appropriate graduation and wording of BODS-1, BODS-2 and the total score, economy and practical usefulness as well as completeness of the BODS. At the end of the questionnaire, respondents were given the opportunity to provide additional comments. The rating scale consisted of five levels: “0 = undecided, 1 = strongly disagree”, 2 = disagree, 3 = agree, 4 = strongly agree”. Levels 3 and 4 were considered acceptable. An analysis of 107 questionnaires that were returned (response rate of 77%) showed high agreement for the relevance of the two scales (87%), their wording (89%) as well as the practicability (80%) and economy (81%). The graduation of the BODS-2 scale and the total score had to be revised. The previous version with 6 stages was extended to the current 8-stage version. After a pilot application, interrater reliability was computed from BODS ratings applied to saliva swallowing and oral intake information from medical charts of 79 neurological patients. Apart from a short manual, the raters did not receive any further instructions. The accordance in the paired comparisons of the 5 raters was very high, i.e., >91.1% for saliva/secretion swallowing and > 97.5 % for oral food intake. In only 1% of the cases, the calculation of the internal consistency yielded discrepancies in one scale value (Cronbach’s alpha = 0.99). The Spearman rank order correlations were > 0.98 for the saliva/secretion swallowing and > 0.96 for oral food intake.

Translation: An English translation of the German version of the score was developed according to the guidelines governing the translation of foreign language measurement tools. Furthermore, with a group of 10 English speaking study participants, a translated version for the FEES examination was validated (Stoll, 2017).

Meanwhile the score was renamed into Munich Swallowing Score (MUCSS-S, MUCSS-N), the items have remained unchanged. The MUCSS-S assesses the ability of swallowing saliva/secretion, the MUCSS-N the ability of oral intake. The MUCSS-S scale ranges from level 1 (no tracheostomy tube, no impairment of saliva/secretion swallowing) to level 8 (permanently inflated tracheostomy tube). The need for a tracheostomy tube for respiratory purposes without saliva/secretion swallowing disorders is not considered in this score. The MUCSS-N scale also ranges from level 1 (completely oral food intake without limitation) to level 8 (solely via feeding tube/parenteral). The two scores can be added to yield a total score (MUCSS-SN), ranging from 2 (best) to 16 (worst). Typically, the MUCSS scoring is based on the results of clinical and/or instrumental evaluation of swallowing. But clinicians also may obtain information from patient files and/or verified patient reports. However, the MUCSS does not represent the quality of the sources of information, but rather operationalizes their results.

After several years of successful testing in daily clinical practice we completed the psychometric characteristics. The aim of the present study was to investigate criterion validity and sensitivity to change of the MUCSS in a cohort of acute/subacute neurological patients. The study sought to investigate the following expectations:

There is a clear pattern of correlations for the admission scores between the MUCSS and clinical as well as fiberendoscopic swallowing measures.

Between MUCSS and scores directly reflecting dysphagic symptoms (GUSS, PAS, YPR, MSS, ERI), strong to moderate correlations are expected.

Between MUCSS and global measures of disability (BI isolated, EBI-subscale cognitive functions), weaker correlations are expected.

The MUCSS reflects clinically relevant differences in swallowing saliva/secretion and oral food intake during a 3-months recovery period.

2 Methods

2.1 Participants and assessment procedures

A consecutive series of 100 neurological patients admitted to the Clinic of Early Rehabilitation and Physical Medicine of a tertiary care academic hospital were included in the study. All participants were inpatients in the acute and subacute phase and had been assessed for swallowing disorders during the period from August 2015 to July 2016. In this facility of early rehabilitation all patients undergo a standardized diagnostic procedure of their swallowing abilities including bedside examination and FEES on admission. Routine follow-up assessments are conducted after four weeks up to three months. We used these existing data that are documented routinely on patient records for our retrospective analysis. An assessor who was not involved in assessment and functional dysphagia treatment of this sample, collected the archived data. Swallowing treatment included rehabilitative exercises and/or compensatory swallowing techniques and/or dietary restrictions (Bartolome 2014). During the inpatient stay all patients received swallowing therapy 5 days per week for 45 minutes per session.

Patients with stroke formed the largest group (39%), followed by critical illness polyneuropathy/-myopathie (25%) and traumatic brain injury (21%). On average, the majority of subjects scored low on the Barthel Index (BI), indicating increased dependency on care at the time of admission to the rehabilitation unit (Table 1).

Table 1
Subject characteristics (N = 100)

Epidemiological features

Men/women, n 66/34

Age, med y (R), men 66 (20–93)

Age, med y (R), women 71 (24–83)

Neurological diagnosis

Stroke, n 39

Infarction (n = 13)

Hemorrhage (n = 26)

Traumatic Brain Injury, n 21

Critical-Illness-Polyneuropathy/Myopathie, n 25

Others (Hypoxia, Neoplasm, Epilepsy, MS), n 15

Initial clinical features (median, range)

BI 0 (0–60)

ERI-subscale –125 (–225–0)

BI/ERI –115 (–175–60)

EBI-subscale cognitive 10 (0–75)

GUSS-total score 7.5 (0–20)

GUSS-severity codes 4 (1–4)

MUCSS-S 6 (1–8)

MUCSS-N 7 (1–8)

MUCSS-SN 12 (2–16)

Initial FEES outcome (median, range)

Aspiration saliva: PAS-S 5 (1–8)

Aspiration oral nutrition: PAS-N 5 (1–8)

Pharyngeal residues saliva: YPR-S Vallecula/Pyriform sinus 3/4 (1–5)

Pharyngeal residues oral nutrition: YPR-N Vallecula/Pyriform sinus 4/5 (1–5)

Accumulated oropharyngeal secretions: MSS 3 (0–3)

The indicators for a tracheostomy tube in this population were severe saliva/secretion aspiration and the need for removal of tracheobronchial saliva/secretion accumulations. Exclusion criteria were non-neurological diseases and lack of FEES diagnosis due to severely decreased consciousness or unstable medical condition. For all subjects, the neurological diagnosis and the type of oral food intake, including the indication for tube feeding and/or for tracheostomy, were determined by the acute neurologic/neurosurgical or intensive care unit of the hospital. At the time of admission to the rehabilitation unit, the MUCSS-grading was carried out by a speech-language therapist through direct patient observation, also considering the handover report. Furthermore, a bedside swallow assessment in accordance to the Gugging Swallowing Screen (GUSS) was conducted as a standard procedure. The GUSS is seen as a valid screening instrument with high sensitivity (Park et al., 2015) and was originally validated for acute stroke patients (Trapl et al., 2007; Warnecke et al., 2017). The FEES was performed by a qualified rehabilitation physician according to the standard protocol proposed by Schröter-Morasch et al. (2014). Prior to the presentation of a bolus, the patient’s pharyngeal secretion accumulation was noted before and after a dry swallow. The first food consistency introduced was puree (jelly), followed by mildly thickened and thin water, each 1x & 1 ml, 2x 3 ml via teaspoon, 2x 5 ml via tablespoon, and then 50 ml thin water via cup, bread without crust, 1.5 cm pieces. All food was dyed with food colouring for contrast (puree green, mildly thickened water blue, thin water green). In cases of intractable aspirations which could not be influenced by therapeutic maneuvers, FEES was aborted. The MUCSS, GUSS and FEES evaluation were conducted within 72 hours of admission to the rehabilitation unit. The nursing staff collected data for the Barthel-Index (BI) (Mahoney & Barthel, 1965), the subscale Early Rehabilitation Barthel Index (ERB) (Schönle, 1995) as well as the subscale extended Barthel-Index (EBI) (Prosiegel et al., 1996) within a maximum of two weeks after admission (mean 6.5 days). The BI was used to assess activities of daily living (ADLs). The ERB defines early rehabilitation procedures and, amongst others, contains the items “tracheostoma requiring special treatment (suctioning)”, “swallowing disorders requiring special supervision” (Rollnik et al., 2016). The EBI evaluates cognitive performances. Despite the time difference to the baseline assessment, we included the Barthel-scores in the evaluation, because they characterise the patient sample in terms of a functional interpretation of the ADLs. Furthermore, the MUCSS assessment was carried out routinely at various points in time to identify longitudinal changes in oral intake and saliva swallowing. All of the mentioned scores including the follow-up results were archived in the patient documentation.

2.2 Criterion validity

In order to measure the criterion validity, the MUCSS scales (MUCSS-S, MUCSS-N, MUCSS-SN) were compared with clinical and fiberendoscopic measures. The clinical measures included the GUSS-total score, the GUSS-severity codes, the BI, the subscale ERI, the BI/ERI-total score and the subscale EBI-cognitive. The fiberendoscopic measures were drawn from FEES videos by determining the level of penetration/aspiration and the severity of pharyngeal residues. For comparisons with MUCSS-S, MUCSS-N and MUCSS-SN, the PAS (Rosenbek et al., 1996) was used regarding penetration/aspiration and the YPR (Neubauer et al., 2015) regarding pharyngeal residues. These diagnostic tools assess both saliva/secretion and food/fluid swallowing. In addition to that, the MSS (Murray et al., 1996) was used for the MUCSS-S evaluation of oropharyngeal secretion accumulation. The validated German versions were applied to the comparison scales named above (Hey et al., 2014; Gerschke et al., 2018; Pluschinski et al., 2014). Two external blinded raters (a laryngologist and a speech-language therapist) with more than 15 years of experience in analysing FEES videos were consulted, who independently carried out the analysis of the videotapes. For each food consistency, the worst result on each scale was noted. In cases of discrepant results, a third external blinded rater was called in and the rating was determined collectively. In total, 907 swallows were analysed with a mean of 9 swallows per patient. The examination needed to be terminated in 5 patients after only 2 sips, in 15 patients all 17 swallows could be performed. These analyses of the clinical and fiberoptic measures were carried out for data obtained on admission to the rehabilitation unit. Since the scales are all ordinally scaled, the correlations were calculated using Spearman’s rank order correlation.

2.3 Sensitivity to change

Changes in the MUCSS during the rehabilitation phase were collected at the time of admission, after 4 weeks and after 3 months. The baseline scoring was carried out by the speech-language therapist who treated the patient. The follow-up scorings were routinely completed by the senior speech-language therapist or her substitute in order to document the longitudinal changes in swallowing abilities. Eighty-six patients were discharged from hospital within the period of 3 months, out of which 76 patients and/or their relatives were asked about the MUCSS items by standardized telephone interviews 3 months after admission. Seven patients could not be reached and 3 patients had died. The Friedman test was applied to detect changes in the MUCSS ranking over time and the Wilcoxon test was used to check pairwise differences. Further, the alpha error level was Bonferroni corrected.

3 Results

3.1 Criterion validity

Highly significant and strong to very strong correlations were found between the clinical evaluation of the dysphagia by the GUSS and all MUCSS scales (Table 2; negative coefficients explained by reverse orders). There was a positive correlation with the GUSS-severity codes, ranging from 1 (best) to 4-(worst), and a negative correlation with the GUSS-total score, ranging from 20 (best) to 0 (worst). The strongest correlation was found between the MUCSS-N and the two GUSS scores. The MUCSS scales showed only weak to moderate correlations with global measures of disability, the BI isolated and the EBI-subscale cognitive functions. Whereas strong to moderate associations were found to the ERI-subscale and to the combined BI/ERI (Table 3).

Table 2
Spearman’s rank correlation coefficients (r_s) and associated p-values between the MUCSS scales and the clinical swallowing assessment with GUSS (taken within 72 hours of admission to rehabilitation unit)

GUSS-total score GUSS-severity score

MUCSS-S r_s –0.642 0.677

p <0.001 <0.001

n 100 100

MUCSS-N r_s –0.824 0.837

p <0.001 <0.001

n 100 100

MUCSS-SN r_s –0.729 0.745

p <0.001 <0.001

n 99 99

		GUSS-total score	GUSS-severity score
MUCSS-S	r_s	–0.642	0.677
	p	<0.001	<0.001
	n	100	100
MUCSS-N	r_s	–0.824	0.837
	p	<0.001	<0.001
	n	100	100
MUCSS-SN	r_s	–0.729	0.745
	p	<0.001	<0.001
	n	99	99

Scale spans: MUCSS-subscales (S/N): 1 (normal) to 8 (abnormal) MUCSS-total score (SN): 2 (normal) to 16 (abnormal) GUSS-total score: 20 (normal) to 0 (abnormal) GUSS-severity codes: 1 (normal) to 4 (abnormal).

Table 3

Spearman’s rank correlation coefficients (r_s) and associated p-values between the MUCSS scales and BI, ERI, BI/ERI-total score, EBI-subscale cognitive functions (averages, 6.5 days after admission to rehabilitation unit)

		BI	ERI	BI/ERI-total	EBI-cognitive
MUCSS-S	r_s	–0.359	–0.685	–0.702	–0.360
	p	<0.001	<0.001	<0.001	<0.001
	n	100	100	100	100
MUCSS-N	r_s	–0.480	–0.483	–0.522	–0.477
	p	<0.001	<0.001	<0.001	<0.001
	n	100	100	100	100
MUCSS-SN	r_s	–0.431	–0.676	–0.700	–0.390
	p	<0.001	<0.001	<0.001	<0.001
	n	99	99	99	99

Scale spans: BI: 100 (normal) to 0 (abnormal) ERI: 0 (normal) to -325 (abnormal) BI + ERI: 100 (normal) to -325 (abnormal) EBI-cognitive: 90 (normal) to 0 (abnormal).

Between the MUCSS-S, MUCSS-N, MUCSS-SN and the FEES scores indicating the physiological swallowing deficits, high correlation values at a high significance level were found (Table 4). The strongest correlation of all MUCSS scores was revealed by the comparison with the degree of penetration/aspiration via PAS (PAS-S, PAS-N, PAS-SN). Considering pharyngeal residues of saliva, there were strong correlations of MUCSS-S with MSS as well as with YPR-S Pyriform sinus, and a moderate correlation with YPR-S Vallecula. MUCSS-N also was significantly associated with the two Yale-subscales indicating pharyngeal residues of food/liquids. Here again the effect for the residues in the pyriform sinus was stronger than in the vallecula. MUCSS-SN was strongly correlated with the combination of the four Yale scale components (YPR-total).

Table 4

Spearman’s rank correlation coefficients (r_s) and associated p-values between the MUCSS scales and FEES assessments with PAS (PAS-S: saliva swallowing, PAS-N: oral nutrition, PAS-total: PAS-S + PAS-N), YPR (YPR-S: saliva swallowing, YPR-N: oral nutrition, YPR-total: YPR-S Vallecula + YPR-S-Pyriform sinus+YPR-N Vallecula+YPR-N Pyriform sinus) and MSS; FEES administered within 72 hours of admission to rehabilitation unit

Saliva swallowing
		PAS-S	YPR-S Vallecula	YPR-S Pyriform sinus	MSS
MUCSS-S	r_s	0.827	0.573	0.639	0.680
	p	<0.001	<0.001	<0.001	<0.001
	n	100	100	100	100
Oral nutrition
		PAS-N	YPR-N Vallecula	YPR-N Pyriform sinus
MUCSS-N	r_s	0.762	0.401	0.702
	p	<0.001	<0.001	<0.001
	n	100	100	100
Saliva swallowing + Oral nutrition
		PAS-total	YPR-total
MUCSS-SN	r_s	0.818	0.678
	p	<0.001	<0.001
	n	100	100

3.2 Sensitivity to change

Figures 1 –3 show the MUCSS scoring at time of admission, after 4 weeks and after three months. Ten participants could no longer be evaluated after three months. The MUCSS-S/-N/-SN were sensitive to recovery of functional swallowing abilities for neurological patients in the acute/subacute phase, declining during follow-up in steps with median values of 6/ 7/ 12 at baseline, 2/ 5.5/ 7.5 after one month and 1/ 2/ 3 after three months. The Friedman chi-square test revealed significant changes for all MUCSS follow-up gradings (Table 5). The subsequently carried out post-hoc tests for the paired comparison (Wilcoxon test) were all significant at the 0.01 level. With Bonferroni correction, significant improvement at a 5% level can be assumed (Table 5).

Fig. 1

Change in the distribution of MUCSS-S ratings at initial assessment within 72 hours of admission to rehabilitation unit, after one month and after three months ^*Missing data after 3 months (deceased n = 3; discharged n = 7).

Fig. 2

Change in the distribution of MUCSS-N ratings at initial assessment within 72 hours of admission to rehabilitation unit, after one month and after three months ^*Missing data after 3 months (deceased n = 3; discharged n = 7).

Fig. 3

Change in the distribution of MUCSS-SN ratings at initial assessment within 72 hours of admission to rehabilitation unit, after one month and after three months ^*Missing data after 3 months (deceased n = 3; discharged n = 7.

Table 5

Friedman tests (χ²) and post-hoc Wilcoxon-tests (Z) for MUCSS-S, MUCSS-N, and MUCSS-SN. Comparisons between examinations A (admission), B (1 month), and C (3 months)

	Friedman χ² (2)	A vs. B	A vs. C	B vs. C
MUCSS-S	96.6^***	–6.9^***	–7.1^***	–5.3^***
		(n = 100)	(n = 90)	(n = 90)
MUCSS-N	128.0^***	–7.3^***	–7.7^***	–6.1^***
		(n = 100)	(n = 90)	(n = 90)
MUCSS-SN	130.9^***	–7.9^***	–7.9^***	–6.6^***
		(n = 99)	(n = 89)	(n = 90)

^***p < 0.001.

4 Discussion

The results of the previously published study reflect an appropriate content validity and a high interrater reliability (Starrost et al., 2012). In the present study the MUCSS showed adequate criterion validity as compared with other swallowing measures. Furthermore, the MUCSS was shown to reflect positive changes in both the status of saliva/secretion swallowing and oral food intake in a group of patients, who are expected to undergo substantial improvements over the time period examined here.

At the time of admission, the status of oral food intake and the type of saliva/secretion management was already defined by the acute care clinic. MUCSS grading, GUSS screening and FEES took place within 72 hours after admission. The correlations between the clinical GUSS screening and the MUCSS scales showed a high level of significance. A very strong association with the MUCSS-N and a strong association with the MUCSS-S was shown both in the GUSS-total score and the GUSS-severity codes. The GUSS evaluates the saliva swallowing with only 3 items, whereas 15 items are provided for the evaluation of food swallowing. The slight discrepancy is probably explained by the different complexity of the scores and this may be a potential explanation for the stronger correlation with the MUCSS-N. Because GUSS and MUCSS were carried out by the same person, this could have led to a distortion of the results. However, the handling of secretion/saliva and oral intake was given by the acute care unit. It was only transferred to the MUCSS level via patient observation, simultaneously considering information from the handover report. Based on the present results, the combination between GUSS and MUCSS grading seems to be feasible for the clinical screening. It offers the possibility to quickly assess the impairment of swallowing and to document the status of handling saliva/secretion and oral food intake in a standardised form. Of course, in cases of suspected dysphagia, it is necessary to carry out a detailed clinical swallowing examination and, if there are clinical signs of pharyngeal residues and/or aspiration, instrumental diagnostics using FEES and/or VFSS are required.

The BI and its subscales were collected by the care staff on average 6.5 days after admission, in few cases only after up to 14 days. Because of the time difference with the MUCSS grading a cautious interpretation of the results appears warranted. In total, there was a significant correlation, suggesting there may be some relationship between MUCSS and deficits in activities of daily living. As expected, scores with a direct link to dysphagia (ERI-subscale and BI/ERI-total) showed a strong correlation to the MUCSS-S, MUCSS-SN and a moderate relationship to MUCSS-N. The clearer connection with the ERI is likely to be explained by the items “tracheostoma requiring special treatment (suctioning)”and “swallowing disorders requiring special supervision”. Whereas considering global measures of disability (BI isolated and EBI-subscale cognitive functions) only weak to moderate correlations were found to MUCSS. In special cases cognitive performances may indeed contribute to the severity of dysphagia. In a patient group with supratentorial lesions Jo et al. (2017) found a meaningful influence of visual attention and executive functions on the oral phase of swallowing.

The comparisons of the MUCSS with the scales of the FEES diagnostics, indicating the physiological swallowing deficits demonstrate a high level of significance. Particularly regarding the PAS, there was the strongest correlation for the MUCSS. Since the saliva/secretion management and the nutritional status depend on the grade of penetration/aspiration, the high correlation to MUCSS-S, respectively MUCSS-N and MUCSS-SN was to be expected. Both the PAS and the MUCSS differentiate the swallowing performance on an 8-point scale, that may potentially make an association more likely. In the validation study of the FOIS (Table 9), that also considers the status of functional oral intake, the VFSS analysis showed a significant correlation with the severity of dysphagia, but not with the degree of aspiration. However, not the PAS was used, but a 5-stage scale with relatively imprecise items (Mann et al., 2000). Divergent results were also shown in Arrese et al. (2019). The study found no correlation between FOIS and the physiological VFSS results in head and neck cancer patients. As an outcome measure, the PAS and the Modified Barium Swallow Impairment Profile (MBSImP©) were used. As a possible reason, the authors suggest the high incidence of silent aspiration within the patient population. Additionally, the FOIS level was only evaluated on the basis of patient surveys. Scores regarding the pharyngeal residues, YPR Pyriform sinus and MSS resulted in a strong correlation for MUCSS-S with a lower concurrent validity for YPR Vallecula. MUCSS-N showed a strong to moderate correlation with regard to the two Yale scales. Here again, the effect for Yale Pyriform sinus seemed to be stronger. MUCSS-SN was also strongly correlated to the combination of the Yale-subscales (YPR-total). The strong association between the presence of endoscopically visible oropharyngeal secretions and the likelihood of aspiration of food and liquids has been demonstrated in several studies (Murray et al., 1996; Ota et al., 2011; Takashi et al., 2012). In contrast to our results, which may assume that residues in the vallecula are less risky than accumulations in the pyriform sinuses, Molfenter and Steele (2013) found that vallecular residue had a greater relative risk of penetration/aspiration than pyriform sinus residues. But this videofluoroscopic study focused on the subsequent clearing swallow and only single sips or teaspoon amounts of ultra-thin liquid barium were analysed.

The MUCSS appears to be sensitive to changes in saliva/secretion swallowing and in the functional oral intake during the acute and subacute phase of rehabilitation in patients with neurogenic dysphagia. Although there are significant changes in MUCSS ratings over time the major weakness of our retrospective design is, that it does not involve an external reference measure to document corresponding changes in clinical status. The follow-up scorings were carried out routinely to document the longitudinal alterations in functional swallowing abilities. Since the raters were members of the rehabilitation staff, a bias in favor of positive treatment effects cannot be excluded. For the inpatients, the handling of secretions and the nutritional status was recorded within the framework of the weekly, interdisciplinary teams. Thereby, the MUCSS allocation was controllable and a bias could be excluded. For 76 test persons who had already been discharged after 4 weeks, the grading at three months follow-up was based on a standardized telephone interview. Maybe it was not always possible to prevent response bias. Since our sample exclusively included patients in the acute and subacute phase of rehabilitation, changes or improvements in swallowing performance can be expected as an effect of treatment and/or spontaneous recovery.

Overall, the preliminary analysis of the MUCSS’s psychometric features yielded positive results. According to the outcomes of the previously published study the score items are precisely operationalized and the status of the saliva/secretion swallowing and the oral food intake can be assessed directly by visual inspection or, if necessary, taken from the written reports (Starrost et al., 2012). The data of the present study show very strong to moderate correlations to scores, which directly reflect clinical signs of dysphagia (GUSS, ERI) and to instrumentally documented pathophysiological swallowing symptoms derived from FEES studies (PAS, YPR, MSS). These results indicate that the MUCSS items may represent the functional swallowing abilities as a consequence of the impaired swallowing physiology.

Decisions on saliva/secretion management and on oral intake can be made in a variety of ways. The MUCSS grading does not reflect the quality of the preliminary examinations and/or the professionalism of the decision makers. There is also a possibility that the patients will self-select their status of saliva/secretion swallowing and/or of the oral food intake due to personal likes or dislikes. Therefore, the MUCSS grading should be carried out after a careful clinical screening and/or the instrumental diagnostics by means of FEES and/or VFSS. Furthermore, individual data on morbidity and possible complications should be considered. In this study, the saliva/secretion management and the nutritional status on admission were determined by the department providing the first aid. Presumably, the professionalism of the colleagues in the acute care clinic contributed to the highly significant associations of the MUCSS with the other swallowing measures on admission.

The MUCSS represents the functional swallowing impairment in everyday life and is allocated to the category “activity limitations” in terms of ICF-based rehabilitation. The items do not include the ICF component “body functions and structure”, but as expected our results showed significant associations between the MUCSS and the physiological scales drawn from FEES videos. Possible correlations between the MUCSS scales and the individual burden of the dysphagia, respectively the ICF component “participation and wellbeing”, should be investigated in future studies. The present pilot study refers to patients suffering from neurogenic dysphagia in the acute and subacute phase of rehabilitation. With an average low BI, this study population is largely dependent on care. Further prospective studies are needed to show for which phases of rehabilitation and patients suffering from dysphagia the MUCSS is an appropriate scale.

5 Conclusion

With the MUCSS an ordinally scaled dysphagia score is available to assess the functional ability of swallowing saliva/secretion and oral food intake. Compared with other swallowing measures, the MUCSS indicates strong criterion validity in the cohort of acute/subacute neurological patients. Furthermore, the MUCSS showed an expected increase in the functional level of swallowing saliva/secretion and oral intake over a 3-months recovery period. MUCSS-S and MUCSS-N can be used separately or added to MUCSS-SN to give a total score. Including the outcomes of the previously published study and according to these preliminary results, the MUCSS is a reliable, valid and practical tool. The scores offer clinicians and researchers a standard approach to measure the functional ability of swallowing saliva/secretions and food/liquids at baseline and to assess changes over time. Moreover, the score can be used as a means of quality assurance, a criterion for the allocation of medical services by the funding agencies. In the future the usefulness of the MUCSS has to be studied in prospective clinical trials with larger groups of patients and longitudinally following patients across time.

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

The study received institutional approval from the ethics committee of the Faculty of Medicine, Technical University Munich, Germany (396/19 S-SR).

Footnotes

Appendix

Münchner Schluckscore (MUCSS) Munich Swallowing Score (MUCSS)

Skala Speichelschlucken (MUCSS-S) Saliva Swallowing Scale (MUCSS-S)
Score 1	Keine Trachealkanüle, Speichelschlucken nicht beeinträchtigt
	No tracheostomy tube, saliva swallowing process not affected
Score 2	Keine Trachealkanüle, gelegentlich gurgelnder Stimmklang und/oder gelegentliche Expektoration (Abstände größer als 1 Std.)
	No tracheostomy tube, occasional wet voice and/or occasional expectoration (less than once an hour)
Score 3	Keine Trachealkanüle, häufig gurgelnder Stimmklang und/oder häufige Expektoration (Abstände kleiner oder gleich 1 Std.)
	No tracheostomy tube, frequent wet voice and/or frequent expectoration (at least once an hour)
Score 4	Trachealkanüle ohne Blockung, Sprechkanüle oder Tracheostoma-Platzhalter als Absaugmöglichkeit für Speichel/Sekret
	Cuffless tracheostomy tube, fenestrated tracheostomy tube or tracheostomy placeholder as means of suctioning saliva/secretion
Score 5	Trachealkanüle tägl. länger als 12 Std. und kürzer als 24 Std. entblockt
	Tracheostomy tube with cuff deflated for intervals between more than 12 hours and less than 24 hours each day
Score 6	Trachealkanüle tägl. länger als 1 Std. und kürzer oder gleich 12 Std. entblockt
	Tracheostomy tube with cuff deflated for intervals between more than one hour and 12 hours each day
Score 7	Trachealkanüle tägl. kürzer oder gleich 1 Std. entblockt
	Tracheostomy tube with cuff deflated for up to one hour each day
Score 8	Trachealkanüle dauerhaft geblockt
	Tracheostomy tube with cuff permanently inflated
Skala orale Nahrungsaufnahme (MUCSS-N) Oral Nutrition Scale (MUCSS-N)
Score 1	Voll orale Nahrungsaufnahme ohne Einschränkung
	No restrictions: Full oral intake
Score 2	Voll orale Nahrungsaufnahme mit geringen Einschränkungen: Mehrere Nahrungskonsistenzen und mindestens eine Flüssigkeitskonsistenz ohne Kompensation oder Kompensation ohne Einschränkung der Nahrungs-/Flüssigkeitskonsistenzen
	Full oral diet with mild restrictions: Multiple food consistencies and at least one liquid consistency consumed without use of compensatory strategy or use of compensatory strategy without dietary limitations
Score 3	Voll orale Nahrungsaufnahme mit mäßigen Einschränkungen: Mehrere Nahrungskonsistenzen und mindestens eine Flüssigkeitskonsistenz mit Kompensation
	Full oral diet with moderate restrictions: Multiple food consistencies and at least one liquid consistency consumed with use of compensatory strategy
Score 4	Voll orale Nahrungsaufnahme mit gravierenden Einschränkungen: Nur eine Nahrungskonsistenz und/oder eine angedickte Flüssigkeitskonsistenz mit oder ohne Kompensation
	Full oral intake with severe restrictions: Only one food consistency and/or one thickened liquid consistency with or without use of compensatory strategy
Score 5	Überwiegend orale Nahrungsaufnahme: Mehr als die Hälfte des Tagesbedarfs, Restbedarf via Sonde/parenteral
	Primarily oral intake: At least fifty percent of daily requirements with additional intake via feeding tube/parenterally
Score 6	Partiell orale Nahrungsaufnahme: Mehr als 10 TL tägl. bis zur Hälfte des Tagesbedarfs, Restbedarf via Sonde/parenteral
	Partial oral intake: At least 10 teaspoons daily up to fifty percent of daily requirements, additional intake via feeding tube/parenterally
Score 7	Minimal orale Nahrungsaufnahme: Weniger oder gleich 10 TL tägl., Restbedarf via Sonde/parenteral
	Minimal oral intake: Up to 10 teaspoons daily, additional intake via feeding tube/parenterally
Score 8	Nahrungsaufnahme ausschließlich via Sonde/parenteral
	No oral intake: All nutritional intake via feeding tube/parenterally

Total score (sum of MUCSS-S and MUCSS-N)

Total score 2: No swallowing disorder

Total score 16: Most severe swallowing disorder.

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Epidemiological features
Men/women, n	66/34
Age, med y (R), men	66 (20–93)
Age, med y (R), women	71 (24–83)
Neurological diagnosis
Stroke, n	39
Infarction (n = 13)
Hemorrhage (n = 26)
Traumatic Brain Injury, n	21
Critical-Illness-Polyneuropathy/Myopathie, n	25
Others (Hypoxia, Neoplasm, Epilepsy, MS), n	15
Initial clinical features (median, range)
BI	0 (0–60)
ERI-subscale	–125 (–225–0)
BI/ERI	–115 (–175–60)
EBI-subscale cognitive	10 (0–75)
GUSS-total score	7.5 (0–20)
GUSS-severity codes	4 (1–4)
MUCSS-S	6 (1–8)
MUCSS-N	7 (1–8)
MUCSS-SN	12 (2–16)
Initial FEES outcome (median, range)
Aspiration saliva: PAS-S	5 (1–8)
Aspiration oral nutrition: PAS-N	5 (1–8)
Pharyngeal residues saliva: YPR-S Vallecula/Pyriform sinus	3/4 (1–5)
Pharyngeal residues oral nutrition: YPR-N Vallecula/Pyriform sinus	4/5 (1–5)
Accumulated oropharyngeal secretions: MSS	3 (0–3)