Reliability and Validity of Korean Mann

Assessment of Swallowing Ability(K-MASA)

Jong-Chi Oh

The Graduate School

Yonsei University

Department of Occupational Therapy

Reliability and Validity of Korean Mann

Assessment of Swallowing Ability(K-MASA)

A Dissertation

Submitted to the Department of Occupational Therapy

and the Graduate School of Yonsei University

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Jong-Chi Oh

December 2013

This certifies that the dissertation of Jong-Chi Oh is approved.

___________________________

Thesis Supervisor: Ji-Hyuk Park

___________________________

Min-Ye Jung

___________________________

Eun-Young Yoo

___________________________

Ki-Yeon Chang

___________________________

Teak-Young Lee

The Graduate School

Yonsei University

December 2013

Acknowledgements

I owe the greatest debt of gratitude to my advisor, Prof. Ji-hyuk Park, who has

supported me unreservedly throughout this work from topic selection to completion of

this paper. My sincere hope is to become a successful researcher doing justice to his great

teachings. My sincere thanks also go to Prof. Min-ye Jung and Prof. Eun-young Yoo who

have provided me with valuable guidance and encouragement all along the path to this

manuscript to make it a worthy work, and Prof. Ki-yeon Jang and Prof. Teak-young Lee

for their insightful comments and encouragement as members of my examination

committee.

I also wish to express my sincere gratitude to Bum-sun Kwon, Department Head of

Dongguk University Ilsan Hospital, who helped me so effectively with subject

recruitment and data collection, as well as Prof. Jin-woo Park, Prof. Ho-jun Lee, Team

Leader Myoeng-ryoel Choi, and Chi-hoon Oh and Ho-jin Hong at the Department of

Occupational Therapy for their persistent efforts in helping me during the data collection.

My sincere thanks are also due to Ji-hyun Choi, Vice President of the Korean

Academy of Dysphagia Rehabilitation, for her contribution to my research with her

competent work of translation and back-translation as well as the translation validation

process, Prof. Ji-young Baik, Prof. Tae-hyun Cha, Prof. Hee-soon Woo, Prof. Sung-yoon

Won, Won-il Song, Kyoung-Chul Min, Sang-min Seo, Su-jung Lee, Bo-un Choi, Hyo-jun

Yang, Sang-gyoon Park, Tu-kyu Kim, and the Academy membersmy apologies for not

naming them one by onewho have always supported and motivated me. My heart-felt

thanks extend to the other side of the Pacific, to Min-soo Park and Jeong-eun Kim for

their participation in the back-translation process. Particular appreciation is expressed to

Prof. Yong-kyoung Kim of Kyungdong University Department of Korean Language

Education for taking his precious time to polish the Korean expressions in this manuscript.

Last but not least, I would like to thank Joo-hyun Lee, Hae-yoon Jung, Young-jo

Kim, and all the other graduate students who have supported me with various kinds of

practical help and advice for smooth progress of my paper, although they are always

devoted to their studies from dawn until dusk at the Graduate School of the Department

of Occupational Therapy. Thank you.

i

Table of Contents

List of Figures ······································································································· iv

List of Tables ·········································································································ⅴ

List of Appendices ································································································ ⅵ

Abstract ················································································································ ⅶ

Introduction ············································································································ 1

Methods ·················································································································· 6

1. Participants ································································································· 6

1.1. Stroke Dysphagic Patients ··································································· 6

2. Instruments ································································································· 9

2.1. Mann Assessment of Swallowing Ability(MASA) ··························· 10

2.2. Content Validity Questionnaire ························································· 12

2.3. Videofluoroscopic swallowing examination(VFSE) ························ 13

2.4. Videofluoroscopic dysphagia scale(VDS) ········································ 14

3. Study Procedure ······················································································· 16

3.1. Tranlation ·························································································· 18

3.2. Content Validity ················································································ 19

ii

3.2.1. Content Validity Verification Committee ································ 19

3.3. Swallowing Examination ·································································· 21

3.4. Validity ······························································································ 22

3.4.1. Concurrent Validity ·································································· 22

3.5. Reliability ·························································································· 22

3.5.1. Internal Consistency ································································· 22

3.5.2. Test-Retest Reliability ······························································ 23

3.5.3. Inter-Rater Reliability ······························································ 25

4. Statistical Analysis ··················································································· 27

Results ·················································································································· 28

1. Translation ································································································ 28

2. Content validity ························································································ 30

3. Concurrent validity ··················································································· 33

4. Reliability ································································································· 35

4.1. Internal Consistency ·········································································· 35

4.2. Test-Retest Reliability ······································································· 36

4.3. Inter-Rater Reliability ······································································· 37

Discussion ············································································································ 39

1. Translation ································································································ 39

iii

2. Validity ····································································································· 40

3. Reliability ································································································· 45

Conclusion ············································································································ 48

References ············································································································ 49

Abstract in Korean ······························································································· 55

Appendix ·············································································································· 58

iv

List of Figures

Figure 1. Study process ····················································································· 17

v

List of Tables

Table 1. Inclusion and exclusion criteria ···························································· 7

Table 2. Demographic characteristics of the participants ··································· 8

Table 3. Demographic characteristics of the respondents participating in the

context validity investigation ····························································· 20

Table 4. Demographic characteristics of the patient participating in the test-

retest reliability ··················································································· 24

Table 5. Demographic characteristics of the patient participating in the inter-

rater reliability ···················································································· 26

Table 6. Tranlation verification results of K-MASA ·············································· 29

Table 7. Responses to questions on the content validity questionnaire ············ 31

Table 8. Content validity index(CVI) of K-MASA ·········································· 32

Table 9. Concurrent validity of K-MASA ························································ 34

Table 10. Interrater, test-retest reliability of K-MASA ····································· 38

vi

List of Appendices

Appendix 1. Mann Assessment of Swallowing Ability(MASA) Instruction

Manual ························································································ 58

Appendix 2. Korean Mann Assessment of Swallowing Ability(K-MASA)

Instruction Manual ····································································· 71

Appendix 3. Clinical Diagnostic Criteria for Dysphagia and Aspiration of

MASA ························································································ 83

Appendix 4. Clinical Diagnostic Criteria for Dysphagia and Aspiration of

K-MASA ···················································································· 84

Appendix 5. Question Investigation for the identification of content validity of

K-MASA ···················································································· 85

Appendix 6. Videofluoroscopic Dysphagia Scale ············································ 96

vii

ABSTRACT

Reliability and Validity of Korean Mann Assessment of Swallowing Ability

Jong-Chi Oh

Dept. of Occupational Therapy

The Graduate School

Yonsei University

The aims of this study was to establish the psychometric properties of the Korean

Mann Assessment of Swallowing Ability (K-MASA) including validity (content validity,

concurrent validity), reliability(test-retest reliability, inter-rater reliability, and internal

consistency).

MASA was translated and back-translated by 2 bilingual experts. Original MASA

and back-translated MASA were compared by native speaker. Understanding of K-

viii

MASA was verified by 2 swallowing rehabilitation experts and scholar of Korean

literature.

10 occupational therapists who have treated dysphagic patients more than 3 years

completed the content validity questionnaire about the K-MASA. The results of the

content validity suggested that the dysphagia professionals’ content review supported the

content validity of each item of the K-MASA for use in individuals with stroke dysphagic

patients. Concurrent validity was assessed using Pearson’s correlation coefficient analysis

about K-MASA results versus Videofluoroscopic Dysphagia Scale (VDS) which

administered to 54 stroke dysphagic patients. Significant correlation was existed between

K-MASA and VDS (correlation coefficient= -.509). There were significant correlation

between subjective judgement about dysphagia and VDS (correlation coefficient= -.650).

Inter-rater reliability and test-retest reliability was calculated with intraclass

coefficients (ICCs) and internal consistency was measured on Cronbach’s alpha. In test-

retest reliability and inter-rater reliability of score scale, ICCs (2, 1) were high (.98, .99).

Test-retest reliability of subjective judgement about dysphagia and aspiration were high

(1.00, 1.00). Inter-rater reliability of subjective judgement about dysphagia and aspiration

were also high (.95, .83). For internal consistency, Cronbach’s alpha for K-MASA 24

items was .92.

In conclusion, the results of present study indicate that the K-MASA holds adequate

content validity, reliability, and concurrent validity for measuring swallowing ability of

ix

Korean stroke dysphagic patients clinically. K-MASA would contribute to more

systematic management of swallowing problems and efficient therapeutic service.

______________________________________________________________________________

Key Words : Deglutition, Dysphagia, Screening, Stroke, Swallowing

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Introduction

The clinical swallowing examination (CSE) is a method for evaluating whether a

subject has dysphagia, which uses various clinical methods such as swallowing difficulty-

related history taking, observation of the anatomical structures of the oral cavity, pharynx,

and larynx, sensory and motor functions, behavior, level of consciousness, speech-

language ability, and trial swallowing (Mann & Lenius, 2008). A CSE is commonly

employed as the first test for dysphagia. Performing costly instrumental examinations on

all patients suspected of dysphagia may incur unnecessary disadvantages in terms of time

and costs. It is therefore useful for suspected acute dysphagia patients to undergo this first

screening test with clinical methods to identify high-risk cases of dysphagia or aspiration

for secondary test via instrumental examination (Martino, Pron, & Diamant, 2000).

The CSE is divided into single- and multiple-item screening methods. The latter

combines various factors associated with aspiration. The single-item screening involves

the patient swallowing a large volume of water and measuring the swallowing speed

(Bours, Spyer, Lemmens, Limburg, & de Wit, 2009; Daniels & Huckabee, 2008). The

multiple-item screening involves combined testing of any of the following items to

confirm or rule out aspiration or dysphagia: anatomical state of the oral cavity and

pharynx, pre- and post-swallowing voice changes, gag reflex, oropharyngeal sensory and

motor function, cough reflex, and respiratory function (Daniels & Huckabee, 2008).

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Because the CSE is performed without using costly testing devices to observe the

interior of the body, it has the advantages of being cost-effective, noninvasive, and less

time-consuming compared to instrumental examination (Mann & Lenius, 2008).

Additionally, the CSE can be used to assess other risk factors that impair the safety of the

swallowing function other than aspiration (Westergren, 2006). The Mann Assessment of

Swallowing Ability (MASA) is one of the clinical assessment tools capable of performing

integrative assessment of such factors.

The MASA is a comprehensive clinical assessment tool designed to assess the extent

of oropharyngeal dysphagia. It is a standardized clinical assessment tool integrating a

variety of aspiration-related items with high reliability and validity. It provides a

systematic method that allows clinicians to evaluate patients’ swallowing ability and

serves as a standardized communication tool among medical professionals regarding the

degree of functional impairment. The assessment item set of MASA comprises high-

validity items selected from the empirical assessment items, which have been

traditionally used in swallowing rehabilitation settings, via literature review related to

clinical assessment. These 24 selected items associated with swallowing ability are

constructed on a score scale in the order of swallowing phases (Mann, 2002).

In the MASA, an operational definition is given to each of its 24 items, and a

detailed explanation is given to each task to be used for testing the patient’s swallowing-

related performance. The score scheme has a distinctive construct that allows independent

assessment of the score scale and total score of all items as well as ordinal risk rating

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regarding dysphagia and aspiration risks. Furthermore, based on the evaluation results of

128 acute stroke patients, patients were grouped according to the level of severity of

dysphagia and aspiration and each group was given a specific cut-off score. This score

serves as the reference value for decisions regarding the patient’s degree of dysphagia

(Mann, 2002). The MASA item and total scores can also be used as a basis for follow-up

observation of the subject’s swallowing ability and inter-subject comparison of

swallowing ability.

The validity of this test was verified by comparing the mean MASA score with the

degree of aspiration and dysphagia of the 128 acute stroke patients as assessed by

videofluoroscopic swallowing examination (VFSE) (Antonios et al., 2010; Gonzalez-

Fernandez, Sein, & Palmer, 2011), and a high rate of inter-rater concordant response was

established with respect to subjective judgment (Mann, 2000). The MASA serves as

concurrent validity in the development of a clinical dysphagia assessment tool, not only

because it is the first standardized clinical assessment tool but also owing to its advantage

of quantifying the degree of swallowing ability (Antonios et al., 2010; Carnaby, Crary,

2013; Crary, Mann, & Groher, 2005; Edmiaston et al., 2010). It is also used in many

dysphagia-related studies as a clinical assessment tool to clinically confirm or rule out the

subject’s dysphagia and to measure the degree of dysphagia (Gonzalez-Fernandez et al.,

2011; Hasan, Al-Shimmery, & Taha, 2010).

While the use of the CSE as a diagnostic tool for confirming or ruling out aspiration

may be limited by its nature of not being as accurate as instrumental examination, it can

- 4 -

derive information that cannot be obtained from an instrumental examination performed

in the laboratory environment in a limited timeframe. Therefore, combining the results of

instrumental examination with those of clinical examination may be conducive to

establishing a comprehensive and effective treatment plan (Daniels & Huckabee, 2008).

In order for the CSE to be able to play such a role, it is crucial to establish a high level of

reliability and an adequate level of validity by verifying the correlation between its results

and those of instrumental examination, which can detect aspiration with accuracy

(Daniels, Anderson, & Willson, 2012).

Unlike most CSE tests performed to ascertain the presence or absence of aspiration,

the MASA can assess the cumulative variables influencing swallowing from the preoral

phase to the pharyngeal stage and has the advantage of evaluating the changes occurring

in the subject at any time owing to the score scale of the 24 swallowing-related items

(Mann, 2002). Therefore, the MASA is likely to fulfill the function of replacing or

complementing VFSE, which can be used only at a limited frequency owing to

radiographic exposure. Now that the use of the MASA for stroke patients is standardized,

extensive research has been conducted to investigate its applicability to other patients

such as those with neurological disease and cancer (Carnaby & Crary, 2013; Gonzalez-

Fernandez et al., 2011).

This paper presents a Korean version of the MASA (K-MASA), the first

standardized CSE test widely used throughout the world, produced through the process of

translation and back-translation. The present study aims to verify the reliability and

- 5 -

validity of K-MASA, thus proving that it is a useful assessment tool that will enable

domestic professionals working in swallowing rehabilitation settings to clinically evaluate

the state of patients with dysphagia.

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Methods

1. Participants

1.1. Stroke Dysphagic Patients

In order to verify the reliability and validity of the K-MASA, the Korean version of

the MASA, a clinical tool for the assessment of swallowing ability, 54 stroke dysphagic

patients (20–90 years) were recruited using the convenience sampling method among the

inpatients at the rehabilitation medicine department of a university hospital located in

Goyang-si, Gyunggi-do. Table 1 outlines the inclusion and exclusion criteria for subject

selection. Voluntary informed consent was obtained from each of the participants after an

explanation of the study purpose, procedure, and possible side effects during the trial. If

patients could not draft the consent themselves because of disease or other reasons, their

legal guardians provided consent for their participation. The mean subject age was 58.6 ±

15.1 years, and the mean period of illness and average Korean Mini Mental State

Examination (MMSE-K) score were 10.9 ± 12.3 months and 25.4 ± 1.5, respectively. All

subjects satisfied the inclusion and exclusion criteria presented in Table 1. The subjects’

demographic characteristics are outlined in Table 2. This study was conducted under the

approval of the Yonsei University Wonju Institutional Review Board.

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Table 1. Inclusion and exclusion criteria

Inclusion Criteria

1. Stroke confirmed by neurologist through CT or MRI

2. Oropharyngeal dysphagia confirmed by a VFSE

3. Have sufficient cognitive function to follow the instruction(MMSE score ≥ 24)

4. Show medically stable status

5. Men and women between 20 and 90 years or age

Exclusion Criteria

1. Dysphagia of other known disease

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Table 2. Demograhphic characteristics of the participants (N= 54)

Number(N) Percent(%)

Gender Male 36 66.7

Female 18 33.3

Age Group 20-40 3 5.6

41-50 15 27.8

51-60 10 18.5

61-70 11 20.4

71-80 12 22.2

81-90 3 5.6

Stroke Type Infarction 24 44.4

Hemorrhage 30 55.6

Lesion Site Rt cortical 20 37.0

Lt cortical 13 24.1

Brainstem 5 9.3

Cerebellum 2 3.7

Mixed 14 25.9

Mean Duration of Illness(Month) 10.9 ± 12.3

Mean MMSE-K(Score) 24.5 ± 1.5

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2. Instruments

In this study, the MASA was used for the Clinical Swallowing Examination (CSE)

of stroke dysphagic patients, and VFSE was performed to ensure an objective evaluation

of the subjects’ actual swallowing abilities. The VFSE results were scored on the

videofluoroscopic dysphagia scale (VDS), consisting of 14 items with a maximum

attainable score of 100. The original MASA in English was translated to Korean and its

content validity, which can determine whether the 24 MASA items are suitable for the

evaluation of the swallowing ability of dysphagic patients, was established by an expert

group via 5-point scale questionnaire.

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2.1. Mann Assessment of Swallowing Ability(MASA)

The MASA was developed by Giselle Mann in 2002 as a comprehensive assessment

tool for the clinical evaluation of oropharyngeal dysphagia.

The MASA consists of 24 clinical items arranged in the order of normal swallowing

phases and designed to evaluate the following three key factors related to the subject’s

swallowing ability: 1) oral motor and sensory elements and preceding skills necessary for

swallowing; 2) functional evaluation of swallowing; and 3) diet recommendation and

predictive risk rating for possible impairment of swallowing integrity. Each assessment

item is provided with the definition of the given item and explanation about the tasks used

for eliciting the subject’s reaction. Each evaluation takes about 15–20 minutes for a

patient who is moderately impaired. The MASA test requires several objects, such as a

tongue depressor, flashlight, gloves, food of different consistencies, and portable water.

The MASA enables quantitative measures reflecting the extent of damage regarding each

item. The measured score of each item is converted into a weighted five- or 10-point

score scale, and the individual scores of the 24 items are summed to yield a final MASA

score/200. This score serves as a reference value for follow-up assessment of the changes

in the state of each patient or inter-patient differences in the degree of dysphagia. Upon

completion of the 24-item evaluation, the observer’s subjective judgment (Mann, 2002) is

additionally generated as the ordinal risk rating for aspiration or dysphagia.

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According to a study conducted by the primary author of MASA, Cronbach’s alpha

coefficient for the entire test is 0.88. The concordance rate between the subjective

judgments of two independent observers, as confirmed with kappa statistics, was reported

to be 0.82 for dysphagia and 0.75 for aspiration. The accuracy rates of the CSE score

scale for dysphagia and aspiration, with the reference value set at 180 points, were 71%

and 93% for sensitivity and 72% and 55% for specificity, respectively. The accuracy rates

of the subjective judgments for dysphagia and aspiration were 73% and 93% for

sensitivity and 89% and 63% for specificity, respectively (Mann, 2002). The original

MASA is presented in Appendix 1.

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2.2. Content Validity Questionnaire

The expert group’s assessment of the K-MASA was scored on a 5-point Likert scale

(very inappropriate, inappropriate, neutral, appropriate, and very appropriate). The

questionnaire was designed for the respondents to provide an assessment of appropriate

or inappropriate to each test item and to give reasons for considering any inappropriate.

The content validity questionnaire is presented in Appendix 5.

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2.3. Videofluoroscopic Swallowing Examination(VFSE)

VFSE is recognized as the gold standard for the evaluation of a subject’s overall

swallowing ability from the oral phase to the esophageal phase while swallowing food of

different consistencies via irradiation of the subject’s anatomical structures associated

with swallowing (Logemann, 1998). In this study, the degree of a subject’s swallowing

ability was evaluated using VFSE (Sonialvision, Shimadzu, Japan), which was

administered by a rehabilitation physiatrist and a radiologist in the fluoroscopic X-ray

room of the radiology department. The subject was asked to sit upright and the evaluator

fixed the subject’s head with their hands. The distance between the X-ray tube and the

subject’s head was maintained at 1.5 meters. The subject was asked to swallow 5 mL of

35% w/v liquid barium, 5 mL of Yoplait, and mashed sweet pumpkin, thrice, respectively.

The test was stopped when excessive aspiration was observed. Side-angle fluoroscopic

images were captured using the Picture Archiving and Communication System (PACS), a

digital imaging and communication system used in medicine. The capture rate was 30

frames/s, and the frame measured 1021 × 1021 pixels.

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2.4. Videofluoroscopic Dysphagia Scale(VDS)

The VDS evaluates the degree of oropharyngeal dysphagia using VFSE findings

(Appendix 6). This scale consists of 14 variables of the oral and pharyngeal phases,

which can yield numerical data on the swallowing ability of stroke patients. A score

proportional to the aspiration relevance is assigned to each itemized variable ranging

from 3 to 13.5 points. The distribution range of the total VDS score is between 0 and 100

points; the more severe the damage to the swallowing ability, the higher the score (Han,

Paik, Park, & Kwon, 2008).

Among the oral phase items, the evaluator assigns lip sealing, bolus formation,

mastication, and tongue-to-palate contact one of the three following possible scores: 0 =

normal; 1 = inappropriate; and 2 = incapable. Apraxia, tongue thrust, and piecemeal

deglutition are evaluated at four levels: 0 = none; 1 = mild; 2 = moderate; and 3 = severe.

Pre-swallow leakage into the pharynx and oral cavity residue are measured at four levels:

0 = none; 1 = <10%; 2 = 10–50%; and 3 = >50%. Oral transit time is also measured.

The pharyngeal phase items that the evaluator observes or measures are the

triggering of pharyngeal swallowing in the pharyngeal phase, laryngeal elevation,

vallecular residue, pyriform sinus residue, coating of the pharyngeal wall after

swallowing, repeated swallowing, and pharyngeal transit time. Vallecular and pyriform

sinus residue are classified into four levels: 0 = none; 1 = <10% on a two-dimensional

surface; 2 = 10–50% of the surface area; and 3 = >50%). Aspiration is evaluated at three

- 15 -

levels: 1 = no aspiration; 2 = laryngeal penetration; and 3 = aspiration. The inter-rater

reliability of the VDS is reported to be 0.56 (Kim et al., 2012). The VDS is presented in

Appendix 6.

- 16 -

3. Study Procedure

In this study, the MASA developed for CSE in stroke dysphagic patients was

translated to Korean, and the validation of the appropriateness of its back-translation as

well as its reliability and validity were established according to the following procedure.

The first stage consisted of the translation of the MASA, back-translation, and

validation of comprehensibility. The second stage included content validity verification of

the K-MASA as a dysphagia assessment tool. In the third stage, in order to verify the

reliability and validity of the final version of the K-MASA, VFSE and the K-MASA were

administered to the dysphagic inpatients between April and July 2013 at a university

hospital located in Goyang-si, Gyunggi-do. VFSE was performed by a rehabilitation

physiatrist and radiologist and the K-MASA test was administered by two occupational

therapists with 7 years of experience in swallowing rehabilitation. To ensure the

reliability of the K-MASA test, the researcher lead a 3-hour training session for the

therapists on the testing and interpretation skills, and the evaluation skills were

sufficiently trained through practice. Fifty-four dysphagic patients participated in the

study. The fourth and fifth stages involved the verification of the reliability and validity

of the K-MASA, respectively.

- 17 -

1. Translation and Adaptation of K-MASA

Translation 2 Bilingual occupational therapists

Back-translation 2 Bilingual occupational therapists

Verification of translation suitability Survey for 2 occupational therapists and

scholar of Korean literature

2. Verification of Content Validity

Content Validity Questionnaire Survey for 10 occupational therapists

3. Swallowing Examination

K-MASA, VFSE 54 stroke dysphagic patients

4. Verification of Reliability

Internal Consistency 54 stroke dysphagic patients

Test-Retest Reliability 10 stroke dysphagic patients

Inter-Rater Reliability 19 stroke dysphagic patients

5. Verification of Validity

Concurrent validity(VDS) 54 stroke dysphagic patients

Fig. 1. Study process

- 18 -

3.1. Translation

The first stage of this study was to translate the English original MASA to Korean

and implement its cultural adaptation. In December 2012, the researcher was given the

approval from the author of the MASA (Giselle Carnaby) to translate and use it for

research purposes. The translation was performed in compliance with the internationally

recognized guidelines (Guillemin, Bombardier, & Beaton, 1993) by two bilingual persons

educated in occupational therapy without any prior experience of using the MASA on a

collaborative basis. The translated MASA was back-translated by two different bilingual

persons educated in occupational therapy without any prior experience of using the

MASA on a collaborative basis. The back-translation was subjected to comparative check

against the original MASA by a native English speaker who was educated in occupational

therapy. When discrepancies between the original and back-translation were discovered,

the same translation and back-translation process was repeated until the two versions

were confirmed to conform entirely. This checked and rechecked preliminary version of

the K-MASA was subjected to a practical comprehensibility test by two occupational

therapists with MA degrees and at least 5 years of work experience. They corrected and

complemented the less-comprehensible portions without any loss or distortion of the

intended meanings. The final K-MASA version was completed after the final linguistic

verification by a scholar of Korean literature. Appendices 1 and 2 present the full versions

of the original MASA and K-MASA, respectively.

- 19 -

3.2. Content Validity

In order to verify the content validity of the K-MASA, 10 professionals, either

occupational therapists with at least 3 years of experience of working with stroke

dysphagic patients or professors of the occupational therapy department, were recruited

using the convenience sampling method. The researcher explained the objective of the

study and the administration methods and scoring of the K-MASA for 1 hour and

distributed the K-MASA manual and content validity questionnaire (Appendix 5)

constructed with a five-point Likert scale, asking the professionals to complete it. The

number of responses corresponding to “appropriate” and “very appropriate” (out of the

options of very inappropriate, inappropriate, neutral, appropriate, and very appropriate)

was divided by the total number of responses, which yielded the item content validity

index (I-CVI) and the scale’s content validity index (S-CVI) (Polit, Beck, & Owen, 2007).

3.2.1. Content Validity Verification Committee

The committee members’ demographic characteristics are outlined in Table 3. The

male-to-female gender ratio was 7:3. None of the committee members participated in the

development of K-MASA. Five were working in a university hospital, two in a general

hospital, and three were university professors. The mean age of the committee was 34.2 ±

4.13 years, and their mean work experience in swallowing rehabilitation therapy was 7.5

± 1.72 years .

- 20 -

Table 3. Demographic characteristics of the respondents participating in the

context validity investigation

(N= 10)

Number (N)

Percent(%)

Gender Male 7 70

Female 3 30

Age (Years) 20-30 2 20

31-40 7 70

41-50 1 10

Occupation Occupational Therapist 7 70

Professor 3 30

Academic Degree Bachelor Degree 4 40

Master Degree 4 40

Doctorate Degree 2 20

Practice Field University Hospital 5 50

General Hospital 2 20

University 3 30

Professional Experience Length (Years)

3-5 1 10

6-8 6 60

9-11 3 30

- 21 -

3.3. Swallowing Examination

Both VFSE, an instrumental screening tool, and the K-MASA, a CSE, were

administered to 54 stroke dysphagic patients in order to test the subjects’ swallowing

ability.

VFSE was administered after the dysphagic patients satisfying the inclusion criteria

of this study had given their consent to participate in the study. To minimize the effect of

neurological recovery on the changes in subjects’ swallowing ability (Mann & Hankey,

2001), the two aforementioned K-MASA-trained occupational therapists administered the

K-MASA to the subjects within 24 hours of VFSE administration (Martino et al., 2009).

The subjects involved in the test-retest reliability process received the first K-MASA test

and received it for the second time from the same therapist within 2 hours (Massey &

Jedlicka, 2002). The subjects involved in the inter-rater reliability process received the

first K-MASA test from one therapist and received the same test for the second time

within 2 hours from the other therapist.

- 22 -

3.4. Validity

3.4.1. Concurrent validity

Fifty-four stroke dysphagic patients participated in the verification process of the

concurrent validity of the K-MASA. To verify the concurrent validity of the K-MASA, an

occupational therapist with over 100 cumulated VFSE analysis hours scored the VFSE

findings in accordance with the scoring standard of the VDS(Han et al., 2008) while

watching the subjects’ swallowing images as often as necessary in video and frame by

frame.

3.5. Reliability

3.5.1. Internal Consistency

The internal consistency for the verification of the reliability of the K-MASA was

tested on the 54 stroke dysphagic patients. Two occupational therapists with 7 years of

work experience in dysphagia rehabilitation determined the Cronbach’s alpha correlation

coefficient on the basis of the scores of the individual items obtained from the K-MASA

test at the department of occupational therapy.

- 23 -

3.5.2. Test-Retest Reliability

Ten stroke dysphagic patients participated in the test-retest reliability of the K-

MASA. The first test was performed during the period of internal consistency testing and

the retest was performed within 2 hours by the same therapist. The results from both tests

were then compared. The subjects’ mean age was 49.9 ± 14.5 years, and the male-to-

female ratio was 8:2. The demographic characteristics of the subjects are outlined in

Table 4.

- 24 -

Table 4. Demograhphic characteristics of the patients participating in the test-retest reliability

(N= 10)

Number(N) Percent(%)

Gender Male 8 80

Female 2 20

Age Group 20-30 1 10

31-40 1 10

41-50 3 30

51-60 2 20

61-70 2 20

71-80 1 10

81-90

Stroke Type Infarction 2 20

Hemorrhage 8 80

Lesion Site Rt cortical 2 20

Lt cortical

Brainstem 2 20

Cerebellum

Mixed 6 60

Mean Duration of Illness(Month) 15.5 ± 8.2

Mean MMSE-K(Score) 25.9 ± 1.9

- 25 -

3.5.3. Inter-Rater Reliability

Nineteen stroke dysphagic patients participated in the inter-rater reliability of the K-

MASA. The first test was performed during the period of internal consistency testing and

the second test was administered by a different therapist within 2 hours. The results from

both tests were then compared. The subjects’ mean age was 54.4 ± 13.6 years and the

male-to-female ratio was 11:8. The demographic characteristics of the subjects are

outlined in Table 5.

- 26 -

Table 5. Demograhphic characteristics of the patients participating in the inter-rater reliability

(N= 10)

Number(N) Percent(%)

Gender Male 11 57.9

Female 8 42.1

Age Group 20-30 1 5.3

31-40

41-50 6 31.6

51-60 6 31.6

61-70 4 21.1

71-80 1 5.3

81-90 1 5.3

Stroke Type Infarction 8 42.1

Hemorrhage 11 57.9

Lesion Site Rt cortical 11 57.9

Lt cortical 7 36.8

Brainstem

Cerebellum 1 5.3

Mixed

Mean Duration of Illness(Month) 3.3 ± 1.6

Mean MMSE-K(Score) 25.2 ± 1.4

- 27 -

4. Statistical Analysis

SPSS 18.0 (SPSS Inc. Chicago, IL, USA) was used for statistical analyses. The

internal consistency of the K-MASA was verified using Cronbach’s alpha, and the

correlation between K-MASA and VDS for the verification of the concurrent validity of

the K-MASA was calculated using Pearson’s correlation coefficient. Both test-retest and

inter-rater reliabilities were verified using the intraclass correlation coefficient (ICCs). All

statistical analyses were considered statistically significant when p < 0.05.

- 28 -

Results

1. Translation

The comprehensibility test of the K-MASA generated through the process of

translation and back-translation led to changes of inadequate terms and phrases and

adaptation of examples to Korean situations within the scope of keeping the original

intention intact. Of the 24 items constituting the score scale of the K-MASA, for the items

in which “tongue coordination” is required, it was necessary to find the words in the

Korean language that solicit the same part of the tongue instead of translating the

example sentences. Thus, the sentence “Take Tim to tea” was replaced with a Korean

sentence requiring a successive tongue-tip movement, “Tazani tazorl tago dallin da”

(Tarzan is riding an ostrich), and the sentence “Can you keep Katie clean?” was replaced

with a Korean sentence requiring a successive tongue-base movement “Camera case ga

quae qeutada.” (Camera case is clean). Apart from such adaptations to evoke the same

effects as the original wordings, all single-syllable phonemes were only transliterated. All

K-MASA items were grammatically checked by a Professor of the Department of Korean

Literature from a university of Korean language education; the results are listed in Table

6.

- 29 -

Table 6. Tranlation verification results of K-MASA

Item Before modification After modification

1.Alertness 각성상태 또는 각성 수준이

오르락내리락 함

각성수준이 높다 낮다 함

2. Cooperation 변동이 심한 협조- 다양한 동

시적 자극에 산만해짐

일관되지 못한 협조- 다양하고

동 시적인 자극에 산만해짐

6. Dysphasia 일반적인 언어기능 손상이 다

양한 언어 양식에서 나타남

언어기능 손상이 다양하게 나

타남

10. Lip Seal

소리 반복과 말 과제 동안 양

입술 기능을 관찰한다.

소리를 반복하게 하고 언어

과제를 수행하는 동안 양 입술

기 능을 관찰한다.

11. Tongue Movement

혀로 입의 양쪽 모서리를 건

드리게 한 후, 양 가쪽 움직임

을 번갈아 반 복시킨다.

혀로 입의 양쪽 모서리를 건드

리게 한 후, 이를 반복하게 한

다.

12. Tongue Strength

명백한 한쪽의 약화 확실한 한쪽의 약화

Appendix 4. for aspiration

음식덩이의 기도진입의 경미

한 위험성을 암시

음식덩이가 기도로 진입할 수

있는 위험성이 경미함을 암시

음식덩이의 기도 진입의 중등

도의 위험성을 암시

음식덩이가 기도로 진입할 수

있는 위험성이 중등도임을 암

시

기도 위협의 상당한 위험성을

암시

기도진입의 위험성이 매우 높

음을 암시

- 30 -

2. Content Validity

Table 7 outlines the results of the responses of the 10 occupational therapy

professionals, including therapists with experience (≥3 years) in treating stroke dysphagic

patients, to the appropriateness of the 24 CSE items of the K-MASA. The content validity

of the 24 items was verified as CSE items in the item content validity index (I-CVI) and

scale’s content validity index (S-CVI). As shown in Table 8, the former distributed within

the range of 0.80–1.00 and the latter was 0.91.

- 31 -

Table 7. Responses to questions on the content validity questionnaire

(N= 10)

Item Very good

N(%)

Good

N(%)

Neutral

N(%)

Bad

N(%)

Very bad

N(%)

1. Alertness 6(60) 2(20) 2(20) 0 0

2. Cooperation 6(60) 3(30) 1(10) 0 0

3. Auditory comprehension 4(40) 5(50) 1(10) 0 0

4. Respiration 6(60) 2(20) 2(20) 0 0

5. Respiratory rate(for swallow) 6(60) 3(30) 1(10) 0 0

6. Dysphasia 5(50) 3(30) 2(20) 0 0

7. Dyspraxia 4(40) 4(40) 2(20) 0 0

8. Dysarthria 5(50) 4(40) 1(10) 0 0

9. Saliva 7(70) 3(30) 0 0 0

10. Lip seal 6(60) 2(20) 2(20) 0 0

11. Tongue movement 7(70) 3(30) 0 0 0

12. Tongue strength 6(60) 4(40) 0 0 0

13. Tongue coordination 8(80) 2(20) 0 0 0

14. Oral preparation 7(70) 2(20) 1(10) 0 0

15. Gag 6(60) 3(30) 1(10) 0 0

16. Palate 6(60) 2(20) 2(20) 0 0

17. Bolus clearance 7(70) 3(30) 0 0 0

18. Oral transit 5(50) 4(40) 1(10) 0 0

19. Cough reflex 7(70) 3(30) 0 0 0

20. Voluntary cough 6(60) 4(40) 0 0 0

21. Voice 4(40) 5(50) 1(10) 0 0

22. Trache 8(80) 2(20) 0 0 0

23. Pharyngeal stage 7(70) 1(10) 2(20) 0 0

24. Pharyngeal response 4(40) 6(60) 0 0 0

- 32 -

Table 8. Content Validity Index(CVI) of K-MASA

(N= 10)

Item Item Content Validity Index

1. Alertness .80

2. Cooperation .90

3. Auditory comprehension .90

4. Respiration .80

5. Respiratory rate(for swallow) .90

6. Dysphasia .80

7. Dyspraxia .80

8. Dysarthria .90

9. Saliva 1.00

10. Lip seal .80

11. Tongue movement 1.00

12. Tongue strength 1.00

13. Tongue coordination 1.00

14. Oral preparation .90

15. Gag .90

16. Palate .80

17. Bolus clearance 1.00

18. Oral transit .90

19. Cough reflex 1.00

20. Voluntary cough 1.00

21. Voice .90

22. Trache 1.00

23. Pharyngeal stage .80

24. Pharyngeal response 1.00

Scale’s Content Validity Index .91

- 33 -

3. Concurrent validity

Pearson’s correlation analysis was performed to verify the correlation between the

findings of the K-MASA test administered to the 54 stroke dysphagic patients and those

of the VFSE-derived VDS(Table 9). There was a significant negative correlation (r = -

0.509; p = 0.000) between the total scores of the K-MASA and VDS, as was between the

VDS results and the total scores of the K-MASA items directly related to swallowing

itself, namely, the oral preparatory phase, bolus clearance, oral transit, pharyngeal phase,

and pharyngeal response (r = -0.546; p = 0.000). A significant negative correlation (r = -

0.650; p = 0.000) was also verified between the VDS results and those of the subjective

judgment about the presence dysphagia in the subjects.

- 34 -

Table 9. Concurrent validity of K-MASA

(N= 54)

Correlation coefficient p-value

K-MASA total score – VDS score -.509 .000**

Swallowing related 5 items score – VDS score -.546 .000**

Subjective judgement(Dysphagia) – VDS score -.650 .000**

Subjective judgement(Aspiration) – VDS score -.642 .000**

**p<.01

- 35 -

4. Reliability

4.1. Internal Consistency

The internal consistency of the items was verified by Cronbach’s alpha. The internal

consistency of the items used for the verification of the reliability of the K-MASA as test

items evaluating swallowing ability using the total scores of the K-MASA test

administered to the 54 stroke dysphagic patients was verified to be 0.92.

- 36 -

4.2. Test-Retest Reliability

The test-retest reliability of the K-MASA test administered to 10 stroke dysphagic

patients were calculated with ICCs. The test-retest reliability of the 24 K-MASA items

was verified to be 0.98, and that of the subjective judgments about dysphagia and

aspiration were both 1.00. Table 10 shows the results of the verification of the ICCs for

each item that was performed in order to verify their test-retest reliability. The test-retest

reliability of each of the 24 items constructed on the score scale was distributed between

0.76 and 1.00.

- 37 -

4.3. Inter-Rater Reliability

The inter-rater reliability of the K-MASA administered to 19 stroke dysphagic

patients was calculated with ICCs. The inter-rater reliability of the 24 K-MASA items

was verified to be 0.99, and that of the subjective judgments about dysphagia and

aspiration were verified to be 0.95 and 0.83, respectively. Table 10 shows the results of

the verification of the ICCs for each item. The inter-rater reliability of each of the 24 was

distributed between 0.70 and 1.00.

- 38 -

Table 10. Interrater, test-retest reliability of K-MASA

Item Interrater reliability

(N= 19)

Test-retest reliability

(N= 10)

1. Alertness .94 1.00

2. Cooperation .79 1.00

3. Auditory comprehension .95 .76

4. Respiration .98 1.00

5. Respiratory rate(for swallow) 1.00 .90

6. Dysphasia 1.22 .97

7. Dyspraxia .98 1.00

8. Dysarthria 1.00 1.00

9. Saliva .99 1.00

10. Lip seal .94 .76

11. Tongue movement .94 1.00

12. Tongue strength .97 1.00

13. Tongue coordination .94 1.00

14. Oral preparation .99 1.00

15. Gag .99 1.00

16. Palate .95 .82

17. Bolus clearance .96 .95

18. Oral transit .97 .94

19. Cough reflex .99 .97

20. Voluntary cough .89 .96

21. Voice .95 .98

22. Trache 1.00 1.00

23. Pharyngeal stage .91 1.00

24. Pharyngeal response .93 .89

K-MASA 24 items .98 .99

- 39 -

Discussion

1. Translation

In this study, internationally recognized guidelines (Guillemin et al., 1993) were

applied to the translation method for completing the Korean version of the MASA.

Evaluation of the qualitative aspects of a translation while taking into account the cultural

context is crucial when translating questions into a language belonging to a different

cultural zone (Peters & Passchier, 2006). To ensure this, the final version of the K-MASA

was completed by translation, back-translation, a check against the original version, and

verification by a Korean literature scholar.

- 40 -

2. Validity

To verify the content validity of the K-MASA, 10 occupational therapy professionals

with long-standing (≥3 years) involvement in stroke dysphagia treatment were convened

to test the necessity of each of the 24 items as a clinical tool for testing swallowing ability.

The validity of all 24 CSE items of the K-MASA as a clinical testing tool were verified.

The creator of the MASA verified its content validity by verifying whether it is composed

with items suitable for clinical testing of swallowing ability by performing a related

literature review (Mann, 2002).

In this study, the content validity of the K-MASA items was verified by involving a

dysphagia rehabilitation expert group via questionnaire survey on content validity by item

and by computing the CVI from the survey results. The item-level index (item content

validity index [I-CVI]) was verified to range between 0.80 and 1.00, and the scale-level

index (scale’s content validity index [S-CVI]), was verified to be 0.91. In general, content

validity is considered high if the item level exceeds 0.78 and the scale-level index

exceeds 0.90 (Polit et al., 2007). Therefore, the K-MASA used in this study is considered

to have a high content validity as a clinical swallowing test tool.

VFSE was used for the verification of the concurrent validity of the K-MASA

administered to the subjects of this study. As another instrumental examination to

objectively evaluate the swallowing ability of the subject, fiberoptic endoscopic

examination of swallowing (FEES) may also be used, but this method has a narrow test

- 41 -

angle and a limited possibility of evaluating the function of swallowing-related structures

such as the upper esophageal sphincter or laryngeal elevation (Kim & Han, 2006). In this

study, VFSE was therefore chosen as a standard diagnostic method because it can

effectively evaluate not only dysphagia or absence thereof but also the structural

dysfunction and movement of oral cavity, pharynx, and esophagus (Lee et al., 2009).

A significant negative correlation (r = -0.509/-0.546) was found between the total K-

MASA score scale of items from 1 to 24 and the VDS as well as between the five items

directly associated with swallowing (oral preparatory phase, bolus clearance, oral transit,

pharyngeal phase, and pharyngeal response). A significant negative correlation (r = -

0.650/-0.642) was also verified between the raters’ subjective judgments about the degree

of dysphagia and the VDS results as well as the raters’ subjective judgments about the

degree of aspiration and the VDS results. Such negative correlation is presumably

attributable to the fact that the higher the MASA score, the higher the swallowing

integrity (Mann, 2002) while the higher the VDS score, the higher the severity of

dysphagia (Han et al., 2008).

The reason for the medium-level correlation between the K-MASA and VFSE-

derived VDS is assumed to be attributable to the different methods used for observing the

subjects’ swallowing ability between the K-MASA and VFSE. While VFSE can observe

only the functions directly associated with swallowing itself, the K-MASA evaluates

additional items influencing swallowing with relatively low direct relevance to

swallowing itself, such as the consciousness level. Considering this inter-item difference

- 42 -

in direct relevance to swallowing, the correlation between the five K-MASA items

directly related to swallowing and the VDS was separately tested and verified to be

higher than the correlation between the total score K-MASA and the VDS.

The swallowing ability assessed through VFSE is not always identical to that

observed during actual meal taking. A study by Robbins et al. (cited in Perry & Love,

2001) revealed that the subjects who showed swallowing apraxia during VFSE could

actually take meals in real daily situations. Given that no clinical screening or swallowing

test can have the same sensitivity or specificity for abnormal swallowing variables or

aspiration as VFSE, it is difficult to present any definite explanation for the discrepancy

between instrumental and clinical examinations (Perry & Love, 2001).

Compared to CSE, VFSE has the advantages of evaluating swallowing mechanisms

and tracking the effects of compensatory techniques during the evaluation. However, the

information provided is dependent on operating procedures and the training of assessors

to interprete results. As for limitations of VFSE, it can be noted that its use depends on

patients’ willingness to undergo an instrumental examination, the availability of the

instrument itself depending on the situation of healthcare providers, and that it has a

limited possibility to be generally accepted in patients’ actual living situations. Owing to

patient radiographic exposure during the examination, its repeat frequency is limited. The

fact that continuous attention should be paid to the patient’s posture to ensure an efficient

examination implies that patients confirmed to be safe in the VFSE test may still be at

risk of aspiration in real-life situations (Ramsey, Smithard, & Kalra, 2003). Although

- 43 -

aspiration is not detected during the VFSE test in certain patients, they can still aspirate

while eating in real situations; therefore, their adverse prognostic effects should be

considered as poor as those of the patients who showed aspiration during the VFSE test

(Smithard et al., 1998).

Furthermore, silent aspiration may have caused the difference between the VFSE test

results and the K-MASA results in this study. While aspiration generally elicits symptoms

such as cough in normal conditions, dysphagic patients have a high rate of silent

aspiration, i.e., they are likely to show no evident symptoms. Silent aspiration was

reported to be present in 15–39% of total stroke patients (Leder, Suiter, & Green, 2011)

and 7–73% of dysphagic patients concomitant with aspiration (Ramsey et al., 2003). With

CSE alone, it is often difficult to judge the presence of aspiration in cases of silent

aspiration because its estimation of swallowing physiology is limited to observing the

apparent reactions or conditions of the patients. Likewise, in a study by Gonzalez-

Fernandez (2011) in which the MASA was administered to dysphagic patients with

various diseases other than stroke, no substantial difference was found in the total MASA

score between the aspiration and non-aspiration groups confirmed as such in the VFSE

test. Despite such inter-tool differences, a statistically significant medium-level

correlation was demonstrated between the VDS and total K-MASA score as well as five

individual swallowing-related K-MASA items administered to stroke dysphagic patients,

which implies that the K-MASA can indirectly reflect a patients’ VFSE-confirmed

swallowing ability. Furthermore, the K-MASA can evaluate various swallowing-related

- 44 -

factors undetectable with VFSE. Therefore, the K-MASA may be utilized between the

initial instrumental examination, such as VFSE testing, to determine the cause and

mechanism of each patient’s dysphagia and the follow-up test, for a continuous regular

clinical follow-up assessment of the patient’s condition by applying it at each treatment or

at an interval of once or twice a week (Mann, 2002). During this period, if patient

improvement or exacerbation is clinically observed, instrumental examination may be

additionally administered in order to confirm the condition or determine the cause by

observing the swallowing mechanism.

In previous MASA-related studies, the VFSE test results, which were categorized

depending on the presence or absence of aspiration (aspiration and non-aspiration) or

degree of dysphagia (normal, mild, moderate, and severe), served as the basis for a

criterion reliability test by comparing them with the MASA score scale or subjective scale

(Antonios et al., 2010; Mann, 2002). In this study, the concurrent validity tests of the

results of the K-MASA score scale and subjective scale were conducted using the 100-

point VDS scale scored on the basis of the VFSE test commonly used for verifying the

condition of dysphagic patients. This test procedure yielded a significant linear

correlation between the K-MASA score scale and subjective scale results and those of the

VFSE test, which is recognized as the gold standard for the evaluation of dysphagia. This

study is significant in that it is the first to verify the correlation between the VDS, the

VFSE-derived score scale, and the MASA, thus proving that the MASA can be used as an

- 45 -

effective follow-up tool for the objective observation of the dysphagic condition of

patients confirmed by the VFSE.

3. Reliability

The internal consistency marks the reliability of an item in terms of its relevance

with other items. The higher the inter-item correlation, the higher the coefficient of the

internal consistency reliability, which is indicative of the degree of homogeneity of a test,

with all its subscales and items testing the same characteristic or ability (Lee, 2012). The

verification of the reliability of the internal consistency of the 24 K-MASA items

administered to the 54 stroke dysphagic patients using Cronbach’s alpha was 0.92.

Compared to total-scale internal consistency of 0.88 as revealed in the study of the

creator of the MASA (Mann, 2002) and 0.94 for the Modified MASA as reported in

another study (Antonios et al., 2010), the total-scale internal consistency of the K-MASA

of 0.92 as confirmed in this study is similar to those confirmed in previous studies.

Therefore, the 24 items constituting the K-MASA are considered to be suitable for

evaluating the subjects’ swallowing abilities.

In this study, the test-retest reliability and inter-rater reliability were confirmed using

ICCs. The test-retest reliability of the original MASA is not presented. The test-retest

- 46 -

reliability for the 24 K-MASA items was verified to be 0.98 and that of the subjective

judgments about dysphagia and aspiration were 1.00, thus demonstrating a very high

level of reliability. Therefore, the reliability of a retest administered by the same rater is

considered very high if the rater receives sufficient training, as was the case in this study.

The inter-rater reliability of the 24 K-MASA items was verified to be 0.99, and that

of the subjective judgments about dysphagia and aspiration were verified to be 0.95 and -

0.83, respectively. The inter-rater reliability tested via yes-no subjective judgment of two

raters and analyzed with kappa statistics, as conducted by the creator of the MASA,

yielded the results of 0.82 for dysphagia and 0.75 for aspiration (Mann, Hankey, &

Cameron, 2000). In the case of the Modified MASA, a 12-item abridged version of the

24-item MASA designed as dysphagic screening test for acute stroke patients, the inter-

rater reliability of subjective judgment about dysphagia estimated using the same method

as the MASA and analyzed with kappa statistics was 0.76 (Antonios et al., 2010).

For comparison, the Gugging swallowing screening (GUSS) and the Toronto bedside

swallowing screening test (TOR-BSST) were used. These tests were developed more

recently and have been used as clinical screening tools for dysphagia. The GUSS inter-

rater consistency for determining the subject’s degree of severity using k-statistics and the

TOR-BSST inter-rater consistency for determining the presence or absence of dysphagia

using ICCs were reported to be 0.84 and 0.92, respectively (Martino et al., 2009; Trapl et

al., 2007).

- 47 -

While the original MASA and Modified MASA verified only the inter-rater

reliability of subjective judgments on two items regarding dysphagia and aspiration

without verifying the reliability of each of the 24 score scale items, all 24 K-MASA score

scale items were tested for their reliability. Therefore, although it is difficult to compare

the results directly with those of previous studies, the high inter-rater reliability yielded

by our study may be attributable to the fact that both raters of the K-MASA had long-

standing clinical experience (7 years) with dysphagic patients and were sufficiently

trained (3 hours) in the implementation of the K-MASA prior to the rating process. In the

verification process of various types of reliability, the lowest reliability was shown by the

inter-rater reliability for the aspiration-related subjective judgment (0.83). This relatively

lower reliability compared to other variables is considered to have arisen from the limited

possibility of clinical estimation of aspiration that should rely on estimation-based

judgment from clinical symptoms under conditions that prohibit direct outward

observation, such as silent aspiration (Gonzalez-Fernandez et al., 2011).

- 48 -

Conclusion

The findings of this study demonstrate the adequacy of the Korean version of the

MASA as a clinical evaluation tool for dysphagic patients by verifying its content validity,

reliability, and validity. The content validity results proved that the K-MASA is

composed of adequate items for the evaluation of dysphagic patients’ swallowing abilities,

and those of the test-retest reliability and inter-rater reliability showed a high level of

reliability. The internal consistency of the 24 items was also verified to be very high.

Thus, the K-MASA was verified to be a very useful tool for the clinical evaluation of

dysphagia in stroke patients. Furthermore, the verification process used to test the content

validity using the VDS, a quantitative evaluation tool based on the findings of VFSE,

yielded a statistically significant correlation between VDS and K-MASA, thus confirming

that the K-MASA is a clinical evaluation tool capable of complementing the drawbacks

of VFSE, the gold standard for the evaluation of dysphagia. It is expected that the K-

MASA will be widely used in clinical settings.

- 49 -

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국문 요약

한국어판 Mann 삼킴 능력 평가(K-MASA)의

신뢰도 및 타당도 연구

연세 학교 학원

작업치료학과

오 종 치

본 연구의 목적은 삼킴 기능에 한 임상적 평가도구인 한국어판

Mann 삼킴 능력 평가(K-MASA)의 타당도 (내용 타당도, 기준타당도)와

신뢰도 (검사-재검사 신뢰도, 검사자간 신뢰도, 내적 일치도)에 한 통계학적

검증을 시행하는 것이다.

작업치료를 전공한 2 인의 이중언어자가 영문 MASA 를 번역 및 역번역

하였으며 원본 MASA 와 역번역된 MASA 를 영어를 모국어로 하는 작업치료

전공자가 비교 검토 후 2 인의 연하재활치료 전문가와 국문학자가 이해도

검증을 실시하였다. 내용 타당도 검증은 K-MASA 의 24 개 항목에 하여

- 56 -

연하장애를 임상적으로 평가하는데 있어 필요도의 정도를 10 명의 연하재활

치료 경력 3 년 이상의 전문가들에게 설문지를 통하여 평가를 의뢰하였다.

내용 타당도 검증 결과 K-MASA 전체 항목의 내용타당도 지수는 .91 로

높은 수준의 내용 타당도가 확인되었다. 공인 타당도의 검증은 뇌졸중으로

인한 연하장애 환자 54 명에게 시행한 시행한 K-MASA 의 결과를 삼킴기능

검사의 절 표준인 비디오영상 투시검사를 이용한 비디오투시검사 연하장애

척도 (VDS) 결과와의 상관 관계를 피어슨 상관분석을 통하여 확인하였다. K-

MASA 와 VDS 간에는 상관계수 -.509 의 유의한 상관관계가 확인되었으며

연하장애의 여부에 한 평가자의 주관적 판단결과와 VDS 간에는 상관계수

-.650 의 유의한 상관관계가 존재하는 것이 확인되었다.

검사-재검사 신뢰도는 연하재활치료 경력 7 년의 작업치료사 1 인이

동일한 환자를 2 시간 이내에 평가한 결과를, 검사자간 신뢰도는

연하재활치료 경력 7 년의 2 인의 작업치료사가 동일한 환자를 2 시간 이내에

평가한 결과에 하여 급내 상관계수를 이용하여 상관분석을 시행하였다. K-

MASA 의 24 개 점수화 척도에 한 평가자간 신뢰도는 .99, 평가-재평가

신뢰도는 .98 로 확인되었으며, 연하장애의 주관적 판단에 한 평가자간

신뢰도는 .95, 기도흡인의 주관적 판단에 한 평가자간 신뢰도는 .83,

연하장애의 주관적 판단에 한 평가-재평가 신뢰도와 기도흡인의 주관적

판단에 한 평가-재평가 신뢰도는 1.00 으로 확인되었다. 삼킴 기능을

임상적으로 평가하는 도구의 항목들로서의 내적 일치도는 Cronbach’s

alpha 를 이용하여 확인한 결과 .92 로 확인되었다.

본 연구 결과를 통하여 한국어판 Mann 삼킴 능력 평가가 내용타당도,

신뢰도와 타당도 측면에서 국내 연하장애 환자들의 삼킴 기능을 임상적으로

평가하는데 적합한 것으로 확인되었다. 이를 통하여 연하재활 치료 시에

- 57 -

환자의 상태를 임상적, 다면적, 정량적으로 파악하여 보다 효율적인 치료를

시행하는데 기여할 수 있을 것이다.

______________________________________________________________________________

핵심 되는 말 : 뇌졸중, 삼킴, 선별, 연하장애

- 58 -

Appendix 1. Mann Assessment of Swallowing Ability (MASA) instruction manual

1. Alertness

A general lack of awareness to environment and self, insensitivity to stimuli, difficulty focusing thought or attention

Task: Observe and evaluate patient’s response to speech, movement, or pain. May incorporate information from medical or nursing staff.

Grade: 10 = Alert

8 = Drowsy - fluctuating awareness/alert level

5 = Difficult to rouse by speech or movement

2 = No response to speech or movement

2. Cooperation

Patient is able to direct his or her attention and interact in activity.

Task: Gain patient’s attention and attempt to initiate communication or activity

Grade: 10 = Cooperative – engages in some form of exchange (verbal/nonverbal)

8 = Fluctuating cooperation – distracted by multiple simultaneous stimuli

5 = Reluctant – unwilling to permit interaction

2 = Unable to cooperate with interaction or activity

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3. Auditory Comprehension

Ability to understand basic verbal communication

Task: Informally engage patient in conversation; ask patient to follow single- and two-stage commands. Utilize both high- and low-probability instructions.

NB: If formal assessment of language completed, results may be incorporated.

Grade: 10 = No abnormality detected on screening

8 = Follows ordinary conversation with little difficulty

6 = Follows simple conversation/ instructions with repetition

4 = Occasional motor response if cued

2 = No/minimal response to speech

4. Respiration

Status of the patient’s respiratory/pulmonary system

Task: Consult medical officer, physiotherapist, or nursing staff regarding the current condition of the patient’s pulmonary system*

Grade: 10 = Chest clear, no evidence of abnormality(clinical/ radiographic)

8 = sputum in the upper airway or other respiratory condition, for example, asthma/ bronchospasm, chronic obstructive airway disease

6 = Fine basal crepitations/ self-clearing

4 = Coarse basal crepitations, receiving chest physiotherapy

2 = Frequent suctioning/ chest physiotherapy/ suspected infection/ respirator dependent

- 60 -

5. Respiratory Rate for Swallow

Respiratory - swallow coordination

Task: Observe respiratory rate at rest

Observe mode of breathing(nasal/ oral)

Observe the timing of patient’s saliva swallowing in relation to inhalation/ exhalation. Note pattern of return from swallow, that is, return to exhalation or not.

Observe timing of cough(if present) in relation to swallow. Ask patient to close mouth to breathe and then hold breath(comfortably); record duration

Grade: 5 = Able to control breath rate for swallow. Patient returns to exhalation post-swallow and can comfortably hold breath 5 seconds.

3 = Some control/ incoordination. Patient can achieve nasal breathing and breath hold for a short period. Patient returns to inhalation on occasion after swallow.

1 = No independent control. Patient mouth breathes predominantly. Patient is unable to hold breath comfortably. Rate of breath is variable.

6. Dysphasia

General language impairment crossing different language modalities: speaking, listening, reading, writing

Task: Informally assess the patient’s verbal expression. This information is to be combined with auditory comprehension examination to determine rating for this item.

repeating sounds, words, sequences

naming objects, numbers, body parts

answering simple questions, Yes/ No

functional naming

Grade: 5 = No abnormality detected on screening

4 = Mild difficulty finding words/ expressing ideas

3 = Expresses self in a limited manner/ short phrases or words

2 = No functional speech- sounds or undecipherable singe words

1 = Unable to assess

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7. Dyspraxia

Impairment in the capacity to order the positioning of the speech musculature or sequence the movements for volitional production of speech. Not accompanied by weakness, slowness, or incoordination of these muscles in reflex or automatic acts.

Task: Informally assess as above. Include repetition of phrases of increasing syllabic length and performance of a range of oral movement to command. Record accuracy, agility, and spontaneous versus imitative productions.

Grade: 5 = No abnormality detected on screening

4 = Speech accurate after trial and error, minor searching movements

3 = Speech crude/ defective in accuracy or speed on command

2 = Significant groping/ inaccuracy, partial or irrevant responses

1 = Unable to assess

8. Dysarthria

Impairment of articulation characterized by disturbance in muscular control over the speech musculature. Includes features such as paralysis, weakness, or incoordination of the speech musculature.

Task: Informally assess as above. Include articulation tasks of increasing length, that is, sentence repetition, reading, and monologue. Engage in conversation. Request patient count to 5, whispering and increasing volume. Diadochokinetic rate may be utilized.

Grade: 5 = No abnormality detected on screening

4 = Slow with occasional hesitation and slurring

3 = Speech intelligible but obviously defective in rate/ range/ strength/ coordination

2 = Speech unintelligible

1 = Unable to assess

- 62 -

9. Saliva

Ability to manage oral secretions

Task: Observe the patient’s control of saliva. Note any escape of secretions from the side of mouth, and check corners of mouth for wetness. Ask the patient if he or she has noticed undue saliva loss during the day, at night, or while side lying

Grade: 5 = No abnormality detected on screening

4 = Frothy/ expectorated into cup

3 = Drooling at times, during speech while side lying, when fatigued

2 = Some drool consistency

1 = Gross drooling. Unable to control drooling, open mouth posture, needing bib protection

10. Lip Seal

Ability to control labial movement and closure

Task: Observe lips at rest. Note tone at corners of mouth

Ask patient to spread lips widely on the vowel /i/ and round for the vowel /u/.

Ask patient to alternate lip movement between the two vowels. Observe bilabial function on earlier sound repetition and speech tasks.

Observe patient’s ability to close mouth around an empty spoon.

Ask patient to blow air into cheeks and maintain closure.

Grade: 5 = No abnormality detected on screening

4 = Mild impairment, occasional leakage

3 = Unilateral weak, poor maintenance, restricted movement

2 = Incomplete closure, limited movement

1 = No closure, unable to assess

- 63 -

11. Tongue Movement

Lingual mobility in both anterior and posterior aspects

Task: Anterior Aspect

Protrusion- Have patient extend tongue as far forward as possible and then retract similarly.

Lateralization- Have patient touch each corner of the mouth, then repeat alternating lateral movements.

With tongue, have patient attempt to clear out lateral sulci on each side of mouth.

Elevation- With mouth open wide, have patient raise tongue tip to alveolar ridge. Alternate elevation and depression in this way.

Posterior Aspect

Elevation- Have patient raise back of tongue to meet palate and hold the position

Grade: 10 = Full range of movement/ no abnormality detected

8 = Mild impairment in range

6 = Incomplete movement

4 = Minimal movement

2 = No movement

12. Tongue Strength

Bilateral lingual strength on resistance tasks

Task: Have patient push laterally, against a tongue depressor or gloved finger.

Have patient push anteriorly, against a tongue depressor or gloved finger.

Have patient push during elevation and depression of the tongue.

Ask patient to elevate back of tongue against a tongue depressor or gloved finger.

Note tone and strength to resistance.

Grade: 10 = No abnormality detected on screening

8 = Minimal weakness

5 = Obvious unilateral weakness

2 = Gross weakness

- 64 -

13. Tongue Coordination

Ability to control lingual movement during serial repetitious activity or speech

Task: Ask patient to lick around lips, slowly and then rapidly, touching all parts.

Have patient rapidly repeat tongue tip alveolar syllables /ta/.

Repeat a sentence including tongue tip alveolar consonants(e.g., Take Tim to tea).

Ask patient to rapidly repeat velar syllables /ka/. Repeat a sentence including velar consonants(e.g., Can you keep Katie clean?).

Grade: 10 = No abnormality detected on screening

8 = Mild incoordination

5 = Gross incoordination

2 = No movement/ unable to assess

14. Oral Preparation

Ability to break down food, mix with saliva, and form a cohesive bolus ready to swallow

Task: Observe patient while eating or chewing. Ask to observe how bolus is prepared prior to swallowing. Check for loss from mouth, position of food bolus, spread throughout oral cavity, and loss of material into lateral or anterior sulci.

Note chewing movements and fatigue.

Grade: 10 = No abnormality detected on screening

8 = Lip or tongue seal, bolus escape

6 = Minimal chew/ tongue thrust bolus projected forward/ limited preparation gravity assisted/ spread throughout mouth/ compensatory head extension

4 = No bolus formation/ no attempt

2 = Unable to assess

- 65 -

15. Gag

Reflex motor response triggered in response to noxious stimuli. It measures response of surface tactile receptors and afferent information travels by way of CN X(and possibly some portion of IX).

Task: Using a laryngeal mirror(size 00) (introduction of cold is optional), contact the base of the tongue or posterior pharyngeal wall. Note any contraction of the pharyngeal wall or soft palate.

Grade: 5 = No abnormality detected, strong symmetrical response/ hyperreflexive

4 = Diminished bilaterally

3 = Diminished unilaterally

2 = Absent unilaterally

1 = No gag response noted

16. Palate

Function of the velum in speech and reflexively

Task: Ask the patient to produce a strong /ah/ and sustain for several seconds.

Ask the patient to repeat /ah/ several times. Note action of elevation.

Observe any hypernasality from earlier speech tasks.

Test palatal reflex- make contact with cold laryngeal mirror at juncture of hard and soft palates.

Grade: 10 = No abnormality detected on screening

8 = Slight asymmetry noted, mobile

6 = Unilaterally weak, inconsistently maintained

4 = Minimal movement, nasal regurgitation, nasal air escape

2 = No spread or elevation

- 66 -

17. Bolus Clearance

Ability to move a bolus effectively through the oral cavity

Task: Observe patient eating/ swallowing a bolus

Check oral cavity for residue following a swallow

Grade: 10 = Bolus fully cleared from mouth

8 = Significant clearance, minimal residue

5 = Some clearance, residue

2 = No clearance

18. Oral Transit

Time from initiation of lingual movement until bolus head reaches point where lower edge of mandible crosses the tongue base.

In clinical measurement, this duration must be timed from the initiation of lingual movement until the initiation of hyoid and laryngeal rise. Thus, the measurement is a crude estimate of time from tongue movement initiation to the trigger of the pharyngeal swallow. Exact oral transit time cannot be separated.

Task: The clinician will position a hand under the patient’s chin, with fingers spread as per manual palpation method(Logemann, 1983). Use only a light touch. Ask the patient to swallow. Compare time elapsed between the initiation of lingual movement until the initiation of hyoid and laryngeal rise. (Normal time for triggering of the pharyngeal swallow is approximately 1 second.)

Grade: 10 = No abnormality detected on screening, triggers rapidly within 1 second

8 = Delay greater than 1 second

6 = Delay greater than 5 seconds

4 = Delay greater than 10 seconds

2 = No movement observed/ unable to assess

- 67 -

19. Cough Reflex

Spontaneous cough in response to an irritant

Task: Information about the effectiveness of the patient’s reflex cough should be assessed in combination with the physiotherapist or other allied health or nursing staff.

Observe any spontaneous coughing during the examination. Cough may be elicited in combination with a respiratory or physical therapist.

Grade: 5 = No abnormality detected on screening, strong reflexive cough

3 = Weak reflexive cough

1 = None observed/ unable to assess

20. Voluntary Cough

Cough response to command

Task: Ask the patient to cough as strongly as possible. Observe strength and clarity of cough.

Grade: 10 = No abnormality detected on screening, strong clear cough

8 = Cough attempted but bovine, hoarse in quality

5 = Attempt inadequate

2 = No attempt/ unable to assess

- 68 -

21. Voice

Evaluation of laryngeal functioning with specific emphasis on vocal quality

Task: Ask the patient to prolong an /ah/ sound for as long as possible.

Ask the patient to slide up and down a scale.

Ask the patient to prolong /s/ and /z/.

Observe clarity of production, pitch, phonation breaks, huskiness, uneven progression, uncontrolled volume(as in previous dysarthria tests), and voice deterioration

Grade: 10 = No abnormality detected on screening

8 = Mild impairment, slight huskiness

6 = Hoarse, difficulty with pitch/ volume control

4 = Wet/ gurgling vocal quality

2 = Aphonic/ unable to assess

22. Trache

Tracheostomy tube to provide ventilator support, facilitate aspiration of tracheobronchial secretions, and/or to bypass a respirator obstruction

Task: Observe the presence of tracheostomy tube; identify reason for insertion.

Information may be gathered from pulmonary physician, medical officer, physiotherapist, or nursing staff.

Grade: 10 = No trache required

5 = Fenestrated trache in situ or uncuffed

1 = Cuffed trache in situ(including those with periods of cuff deflation)

- 69 -

23. Pharyngeal Phase

Integrity of pharyngeal function from triggering of swallow until bolus passes through cricopharyngeal sphincter. It is clinically identified by hyolaryngeal movement.

Task: Observe hyoid and laryngeal movement using manual palpation method(Logemann, 1983). Note smoothness of excursion and maximal elevation point.

Following swallow, ask patient to phonate /ah/ for several seconds. Note vocal quality.

Ask patient to pant following swallow then vocalize. Note vocal quality.

Ask patient to turn head to each side and vocalize. Note vocal quality.

Ask patient to lift chin and vocalize. Note vocal quality.

Grade: 10 = Immediate laryngeal elevation and complete clearance of material

8 = Laryngeal elevation mildly restricted, slow initiation of rise, incomplete clearance of material

5 = Incomplete laryngeal elevation, jerking incoordinated progression, pooling/ gurgling on phonation

2 = No swallow initiated/ unable to assess

24. Pharyngeal Response

Control of the bolus through the pharyngeal region and management and response to stasis of materials

Task: Observe vocal quality and coughing as a result of swallow. To be completed in association with other assessment tasks

Grade: 10 = No abnormality detected on screening

5 = Coughing before/ during/ after the swallow has triggered

1 = Not coping, gurgling

- 70 -

Diet Recommendations

Dietary recommendations as a response to clinical swallowing evaluation completed as above. This may form an interim dietary management plan until further objective analysis of swallowing function is completed. Careful consideration of the risk to the patient, in the selection of different consistencies of diet/fluids prior to or in the absence of other instrumental assessment techniques is required.

Grade: (Solids) Nil by mouth(NBM)- Risk too great to feed orally

Thickened/ vitamized diet(puree)

Modified soft diet(minced/ mashed)

Soft diet

Normal- no alternation to consistency

(Fluids) NBM

Thickened fluid- batter consistency

Thickened fluid- honey consistency

Thickened fluid- nectar consistency

Normal fluids- no alteration to consistency

Swallow Integrity

Ordinal risk rating for the two major outcomes of the clinical swallowing assessment: dysphagia and aspiration

Grades: Definite

Probable

Possible

Unlikely

- 71 -

Appendix 2. Korean Mann Assessment of Swallowing Ability(K-MASA) Instruction Manual

1. 각성수준

환경 및 자신에 한 일반적인 인식 부족, 자극에 한 무감각, 생각이나 주의 집중에 어려움을

보임

과제: - 말, 움직임, 통증에 한 환자의 반응을 관찰하고 평가한다.

- 의사 또는 간호사로부터 받은 관련 정보를 포함할 수 있다.

등급: 10 = 정신이 명료함

8 = 졸림- 각성 수준이 높다 낮다함

5 = 말이나 움직임으로 깨우기 어려움

2 = 말이나 움직임에 반응이 없음

2. 협조

환자는 주의를 기울일 수 있으며 활동 내에서 상호작용할 수 있음

과제: - 환자의 주의를 끌어 의사소통이나 활동을 시도한다.

등급: 10 = 협조적- 상호적 소통을 함(언어적/ 비언어적)

8 = 일관되지 못한 협조- 다양하고 동시적인 자극에 산만해짐

5 = 상호작용을 꺼림 – 상호작용을 원하지 않음

2 = 상호작용 또는 활동에 협조하지 않음

3. 청각적 이해

기본적인 언어적 의사소통을 이해할 수 있는 능력

과제: - 특별한 형식 없이 환자를 화에 참여시킨다;

- 1-2 단계의 지시 따르기를 수행시킨다.

- 수행하기 쉬운 지시와 수행하기 어려운 지시 모두를 사용한다.

주의: 정식 언어평가 결과가 있는 경우는 참고한다

등급: 10 = 정상

8 = 약간의 어려움을 보이나, 일상적인 화를 이해함

6 = 여러 번 반복하여 지시하면 간단한 화나 지시사항을 이해함

4 = 신호를 주면 가끔 운동 반응을 보임

2 = 말에 아무런 반응을 보이지 않거나 반응이 매우 적음

- 72 -

4. 호흡

환자의 호흡기계 / 폐의 상태

과제: - 환자의 호흡기계 상태에 관해 의료진, 물리치료사 혹은 간호사 등에게

문의한다*

등급: 10 = 흉부가 깨끗하고, 정상적임(임상적/ 방사선 촬영 상)

8 = 상부 기도에 가래가 있음 또는 다른 호흡기계 상태, 예를 들면 천식,

기관지 연축, 만성폐쇄성 기도질환

6 = 호흡시 미세한 마찰음이 들림/ 스스로 헛기침 가능

4 = 호흡시 거친 마찰음이 들림, 호흡기 물리치료를 받고 있음

2 = 상기도 내 분비물을 흡입기로 빈번하게 빨아냄/ 호흡기 물리치료/ 호흡기

감염이 의심됨/ 호흡기에 의존

*주: 환자의 활동 수준에 주목한다

5. 삼킴에 한 호흡률

호흡과 삼킴의 협응

과제:

- 휴식 시 호흡 속도를 관찰한다.

- 호흡 방식을 관찰한다(비강호흡/ 구강호흡).

- 흡기/ 호기와 관련된 침 삼킴 시기를 관찰한다.

- 삼킴 후 호흡으로의 복귀 양상을 주목- 침을 삼킨 후 호기로 돌아오는지

여부를 관찰한다.

- (기침을 할 경우), 삼킴과 관련된 기침 시기를 관찰한다.

- 환자에게 입을 다물게 하고 호흡을 하다가, 편안하게 호흡을 멈추게 한다:

숨을 참을 수 있는 시간을 기록한다.

등급: 5 = 삼킴을 위해 호흡을 조절할 수 있음. 삼킴 후 호기로 돌아오고 숨을

5 초간 편안하게 멈출 수 있음

3 = 약간의 조절/ 조화운동 불능. 환자는 코로 숨을 쉴 수 있으며, 숨을 잠깐

멈출 수 있음. 환자는 가끔씩 삼킴 후에 숨을 들이마심

1 = 독립적인 조절이 안 됨. 부분 입으로 숨을 쉼. 숨을 편안하게 멈추지

못함. 호흡 속도는 변동이 심함

- 73 -

6. 실어증

언어기능 손상이 다양하게 나타남: 말하기, 듣기, 읽기, 쓰기

과제:

- 환자의 구어적 표현을 특별한 형식 없이 평가한다. 본 항목의 채점을 위해

‘청각적 이해’ 항목의 결과를 함께 사용한다.

- 소리, 단어, 수열 반복하기

- 사물, 숫자, 신체 부위 이름 기

- 간단한 질문에 답하기, 예/ 아니오

- 기능적 이름 기

등급: 5 = 정상

4 = 단어 생각해내기/ 생각 표현하기에서 약간의 어려움

3 = 표현하는데 제한을 보임/ 짧은 구 또는 단어를 사용

2 = 기능적인 말을 하지 못함- 소리 또는 이해할 수 없는 단어 사용

1 = 평가 불가

7. 협동운동 장애

의지적으로 말하기 위해 말과 관련된 근육의 자세를 잡거나 움직임을 차례 로 배열하는

능력의 손상. 반사적으로 또는 자연스럽게 나오는 행동에서는 이 근육들의 약화, 속도 저하

또는 협응 장애가 동반되지 않음

과제:

- ‘실어증’ 항목 평가와 같이 특별한 형식 없이 평가한다.

- 음절의 길이를 증가시킨 구를 반복시키거나, 지시에 따른 다양한 구강의

움직임을 포함한다.

- 정확성, 민첩성 그리고 모방에 의한 움직임과 자연스러운 상황에서의

움직임을 기록한다.

등급: 5 = 정상

4 = 시행착오 후 정확히 말을 하며 약간의 탐색적 움직임을 보임

3 = 지시에 따라 수행 시, 말이 어눌함/ 정확성 또는 속도가 감소

2 = 현저한 말더듬/ 부정확, 불완전한 반응 또는 관련 없는 반응을 보임

1 = 평가 불가

- 74 -

8. 조음 장애

말과 관련된 근육의 조절 장애가 특징인 발음장애; 말과 관련된 근육의 마비, 약화, 또는

협동장애를 포함

과제:

- 특별한 형식 없이 평가한다.

- 길이를 증가시키는 발음 과제들을 포함한다; 문장 반복, 읽기, 독백. 화에

참여시킨다.

- 5 까지 세어보도록 한다- 속삭이듯이 말해보게 하고, 점차로 소리를 키워보

도록 한다. 상반운동 반복률*을 사용할 수 있다.

등급: 5 = 정상

4 = 이따금씩 주저하고 불분명한 발음을 보이며, 속도가 느림

3 = 말을 이해할 수는 있으나 ‘속도/ 범위/ 힘/ 협응’이 현저히 부족함

2 = 말을 이해할 수 없음

1 = 평가 불가

*주: 빠른 교차음의 연속을 얼마나 빠르게 정확하게 하는지 평가하는 방법.

예) 푸-투-쿠를 반복

9. 침

침을 관리할 수 있는 능력

과제:

- 침을 어떻게 관리하는지 관찰한다.

- 침이 입 옆으로 새어 나오는지, 입 양끝이 젖어있는지 확인한다.

- 일과시간 중에, 밤에 또는 옆으로 누워있을 때 과도한 침이 새어 나온 적이

있는지 물어본다.

등급: 5 = 정상

4 = 컵에 침을 뱉어냄

3 = 옆으로 누워 이야기할 때, 피로할 때 가끔 침을 흘림

2 = 지속적으로 약간의 침 흘림이 있음

1 = 상당한 침 흘림. 침 흘림을 조절할 수 없음, 입을 벌리고 있음, 턱받이가

필요함

- 75 -

10. 입술 다물기

입술의 움직임과 닫힘을 조절할 수 있는 능력

과제: - 휴식 시 입술을 관찰한다.

- 입술 가장자리의 긴장도를 확인한다.

- 환자에게 ‘이’ 발음을 하면서 입술을 넓게 벌리게 하고, ‘우’ 발음을 하면서

입술을 둥글게 모으게 한다.

- 두 모음간의 입술 움직임을 번갈아 가며 하라고 요청한다.

- 앞에서 사용한 소리를 반복하게 하고 언어 과제를 수행하는 동안 양 입술

기능을 관찰한다.

- 빈 수저를 물고 입술을 다무는 능력을 관찰한다.

- 환자에게 볼에 바람을 불어넣고 입술을 다문 채 유지하도록 요청한다.

등급: 5 = 정상

4 = 약간의 손상, 가끔 새어 나옴

3 = 한쪽의 약화, 유지가 어려움, 한정된 움직임.

2 = 불완전한 닫힘, 약간의 움직임만이 가능

1 = 닫히지 않음, 평가 불가

11. 혀의 움직임

혀의 앞쪽과 뒤쪽의 가동성

과제: 혀의 앞쪽

- 혀 내밀기: 환자에게 혀를 최 한 앞으로 내밀었다 뒤로 당기게 한다.

- 바깥쪽으로 움직이기:

- 혀로 입의 양쪽 모서리를 건드리게 한 후, 이를 반복하게 한다.

- 혀로 구강 내 좌우 바깥쪽 볼 고랑을 훑어보도록 한다.

- 위로 올리기:

- 입을 크게 벌린 상태에서, 혀끝을 치조능선까지 올려보게 한다.

- 이러한 방법으로 위로 올리기와 아래로 내리기를 반복시킨다.

혀의 뒤쪽

- 위로 올리기: 혀의 뒤쪽을 들어올려 구개에 닿게 하고, 그 자세를 유지

시킨다.

등급: 10 = 전 범위 움직임이 가능/ 정상

8 = 움직임의 범위에 약간의 제한이 있음

6 = 불완전한 움직임

4 = 아주 작은 움직임

2 = 전혀 움직이지 않음

- 76 -

12. 혀의 근력

저항과제에 한 혀의 양쪽 근력

과제:

- 설압자 또는 장갑을 낀 평가자의 손가락에 항하여 혀를 바깥쪽으로

밀어내도록 한다.

- 설압자 또는 장갑을 낀 평가자의 손가락에 항하여 혀를 앞쪽으로 밀도록

한다.

- 혀를 위쪽과 아래쪽으로 밀어보도록 한다.

- 설압자 또는 장갑을 낀 평가자의 손가락에 항하여 혀의 뒤쪽을 위로

올려보도록 요청한다.

- 저항에 한 긴장도와 근력을 확인한다.

등급: 10 = 정상

8 = 약간의 약화

5 = 확실한 한쪽의 약화

2 = 전반적인 약화

13. 혀의 협응

순차적인 반복 활동 또는 말을 하는 동안 혀의 움직임을 조절할 수 있는 능력

과제:

- 입술 주변을 핥아보도록 요청한다; 느리게 그리고 빠르게 입술의 모든

부분을 건드리게 한다.

- 혀 끝 치조음절인 ‘타’를 빠르게 반복시킨다.

- 혀 끝 치조 자음을 포함하는 문장을 반복시킨다(예: ‘타잔이 타조를 타고

달린다.’)

- 연구개 음절인 ‘카’를 빠르게 반복하라고 요청한다.

- 연구개 자음을 포함하는 문장을 반복시킨다(예: ‘카메라 케이스가 깨끗

하다.’).

등급: 10 = 정상

8 = 약간의 협응 장애

5 = 전반적 협응 장애

2 = 움직임이 없음/ 평가 불가

- 77 -

14. 구강 준비

음식을 잘게 부수고, 침과 섞어, 삼킬 준비가 된 응집력 있는 음식덩이를 형성하는 능력

과제: - 먹거나 씹는 동안 환자를 관찰한다.

- 삼키기 전에 음식덩이가 어떻게 준비되었는지 보여달라고 한다.

- 구강으로부터의 소실, 음식덩이의 위치, 구강 내 퍼짐, 바깥쪽 또는 앞쪽

고랑 내로 음식물이 빠져나갔는지 확인한다.

- 씹는 동작과 피로감을 관찰한다.

등급: 10 = 정상

8 = 입술 또는 혀로 새지 않게 막고 있으나 음식덩이가 유출됨.

6 = ‘아주 적은 씹기/ 혀 내밀기 반사’로 인하여 음식덩이가 앞쪽으로

밀려나옴 / 중력의 도움을 받아 수행하지만 음식덩이 준비가 제한됨/

구강 내에 퍼져 있음/ 보상적으로 머리의 젖힘을 이용

4 = 음식덩이 형성이 안됨 / 시도하지 않음

2 = 평가 불가

15. 구역 반사

해로운 자극에 한 반응으로 유발되는 반사적 운동 반응. 10 번 뇌신경에 의한 표면의 촉각 수

용기와 구심성 정보 전달의 반응을 평가(일부는 9 번 뇌신경의 기능일 수도 있음)

과제:

- 00 규격의 후두경을 사용하여(차갑게 해서 제공하는 것은 선택사항) 혀의

바닥부위 또는 뒤쪽 인두벽을 건드린다.

- 인두벽 또는 연구개의 수축을 확인한다.

등급: 5 = 정상. 강한 칭성 반응/ 반사항진

4 = 양쪽 모두 감소

3 = 한쪽만 감소

2 = 한쪽만 소실

1 = 반응 없음

- 78 -

16. 입천장

반사작용과 말하기에서 연구개의 기능

과제: - ‘아’ 소리를 강하게 몇 초간 지속하라고 요청한다.

- ‘아’ 소리를 여러 번 반복하라고 요청한다. 입천장이 위로 올라가는지

확인한다.

- 이전에 시행한 말 관련 과제에서 과다한 콧소리가 들리는지 관찰한다.

- 입천장 반사(palatal reflex, 차가운 후두경을 경구개와 연구개가 만나는

지점에 가져다 댄다)를 확인한다.

등급: 10 = 정상

8 = 잘 움직이지만 약간의 비 칭이 관찰됨

6 = 한쪽의 약화, 유지되는 정도가 비일관적임

4 = 아주 적은 움직임, 비강 역류, 비강 공기 탈출

2 = 연구개가 펼쳐지거나 위로 올라가지 않음

17. 음식덩이 제거

구강 내에서 음식덩이를 효율적으로 움직이는 능력

과제:

- 음식덩이를 먹고 삼키는 것을 관찰한다.

- 삼킴 후에 구강 내 잔여물을 확인한다.

등급: 10 = 구강 내에서 음식덩이가 완전히 제거됨

8 = 현저한 제거, 아주 적은 잔여물

5 = 약간 제거, 잔여물 남음

2 = 전혀 제거되지 않음

- 79 -

18. 구강 통과

혀의 움직임이 시작되었을 때부터 음식덩이의 머리 부분이 혀의 바닥을 지나 아래턱뼈의

아래쪽 모서리에 도달할 때까지 소요되는 시간.

임상적 측정에서, 이 기간은 혀의 움직임이 시작되었을 때부터 목뿔뼈 및 후두의 상승이

시작될 때까지의 시간을 측정하여야 한다.

따라서 시간 측정은 혀의 움직임이 시작되었을 때부터 인두 삼킴이 시작될 때까지의 시간을

추정한 것이다. 정확한 구강 통과시간을 측정할 수는 없다.

과제:

- 임상가는 손 촉진 방법(Logemann, 1983)에 따라 손을 환자의 턱 아래에

손가락을 벌려 가져다 댄다. 살짝 가져다 기만 한다.

- 환자에게 삼키도록 요청한다.

- 혀의 움직임이 시작될 때부터 목뿔뼈와 후두의 상승이 시작될 때까지의

시간을 측정한다(인두 삼킴 시작의 정상 시간은 약 1 초이다).

등급: 10 = 정상. 후두 상승이 1 초 이내 빠르게 시작됨

8 = 후두 상승이 1 초 이상 지연됨

6 = 후두 상승이 5 초 이상 지연됨

4 = 후두 상승이 10 초 이상 지연됨

2 = 움직임이 관찰되지 않음/ 평가 불가

19. 기침 반사

자극물에 한 반응으로 나타나는 반사적 기침

과제:

- 환자의 반사적 기침의 효율성에 한 정보는 물리치료사 또는 다른 관련

전문가 또는 간호사들과 함께 평가되어야 한다.

- 검사 도중에 나타나는 환자의 반사적 기침을 관찰한다.

- 기침은 호흡치료사 또는 물리치료사와 함께 이끌어낼 수도 있다.

등급:

5 = 정상. 강한 반사적 기침

3 = 약한 반사적 기침

1 = 전혀 관찰되지 않음/ 평가 불가

- 80 -

20. 자발적 기침

지시에 따른 기침 반응

과제: - 가능한 최 한 세게 기침을 해보도록 요청한다.

- 기침의 힘과 명확성을 관찰한다.

등급: 10 = 정상. 강하고 명확한 기침

8 = 기침을 시도하나 둔탁하고, 쉰 소리가 남

5 = 시도는 하나 기침이 나오기엔 불충분함

2 = 시도하지 않음/ 평가 불가

21. 목소리

목소리의 질에 특히 초점을 맞추어 후두의 기능을 평가

과제:

- ‘아’ 소리를 최 한 길게 내 보도록 요청한다.

- 음계를 위, 아래로 조절해보라고 요청한다.

- ‘스’와 ‘즈’ 발음을 길게 내 보라고 요청한다.

- 발음의 명료함, 음의 고저, 일시적인 발성일탈, 쉰 목소리, 고르지 않은

진행, 음량 조절이 안됨(‘조음장애’ 검사에서처럼), 목소리가 악화되는지

등을 관찰한다.

등급: 10 = 정상

8 = 약간의 손상, 경미한 쉰소리

6 = 쉰소리, 음의 고저와 음량의 조절이 어려움

4 = 젖은(목구멍에서 그르렁 거리는(gurgling)) 소리가 남

2 = 소리를 내지 못함/ 평가 불가

- 81 -

22. 기관 절개관

폐의 환기를 보조하고, 기관기관지 분비물을 기구로 빨아내는 것을 용이하게 하고, 기도 막힘을

예방하기 위한 기관 절개관

과제:

- 기관 절개관의 유무를 관찰한다; 기관 절개관 삽입의 이유를 확인한다.

- 정보는 호흡기 의사, 의료진, 물리치료사 또는 간호사로부터 얻을 수도

있다.

등급: 10 = 기관 절개관이 불필요함

5 = 창이 있는 기관 절개관 또는 풍선이 없는 기관 절개관

1 = 풍선이 있는 기관 절개관(공기를 뺀 기간도 포함)

23. 인두기

삼킴이 유발되었을 때부터 음식덩이가 윤상 인두 괄약근을 통과할 때까지 인두기능의 온전함.

이는 임상적으로 후두복합체의 움직임으로 확인된다.

과제:

- 손 촉진 방법(Logemann, 1983)을 이용하여 목뿔뼈와 후두의 움직임을

관찰한다.

- 운동의 매끄러움과 최 로 올라간 지점을 확인한다.

- 음식물을 삼킨 후, 몇 초간 ‘아’ 소리를 내도록 한다. 목소리의 질을

확인한다.

- 음식물을 삼킨 후에 숨을 헐떡이게 한 후, 소리를 내도록 요청한다.

목소리의 질을 확인한다.

- 고개를 왼쪽 또는 오른쪽으로 돌리게 한 후, 각 자세에서 소리를 내도록

요청한다. 목소리의 질을 확인한다.

- 턱을 위로 들고 소리를 내도록 요청한다. 목소리의 질을 확인한다.

등급: 10 = 즉각적인 후두의 상승과 물질의 완전한 제거

8 = 약간 제한된 후두 상승, 상승이 느리게 시작됨, 물질이 불완전하게

제거됨

5 = 불완전한 후두 상승, 경련성 움직임, 발성 시 물질이 고여 있는 듯한

(그르렁 거리는 소리(gurgling))

2 = 삼킴이 시작되지 않음/ 평가 불가

- 82 -

24. 인두 반응

인두 영역에서의 음식덩이의 조절, 그리고 물질의 정체에 한 반응과 조절

과제:

- 삼킴 후에 목소리의 질과 기침을 관찰한다.

- 다른 평가 과제들과 함께 시행되어야 한다.

등급:

10 = 정상

5 = 삼킴 전/삼키는 도중/삼킴 후에 기침이 나옴

1 = 처하지 않음, 그르렁거림(gurgling)

식이 추천

상기와 같이 완료된 임상 삼킴 평가에 한 결과를 바탕으로 식이를 추천.

이는 추후의 삼킴 기능의 객관적 분석이 완료될 때까지 잠정적인 식이 관리 계획의 기능을 할

수 있음. 다른 도구를 이용한 평가를 실시하기 전이거나 부재 시 식이 또는 액체의 다양한

농도의 선택에 있어 환자에게 가해질 위험에 한 신중한 고려가 요구됨

등급:(고형식) - 금식: 구강 섭취를 하기엔 너무 위험

- 걸쭉한 균일농도의 음식(퓨레)

- 변형된 부드러운 음식(갈거나 으깸)

- 부드러운 음식

- 일반식: 농도에 변화를 주지 않음

등급:(음 료) - 금식

- 걸쭉한 액체- 반죽 농도

- 걸쭉한 액체- 꿀 농도

- 걸쭉한 액체- 과즙 농도

- 일반 액체- 농도에 변화를 주지 않음

삼킴의 온전함

임상 삼킴 평가의 두 개의 주요 결과인 연하장애와 기도흡인에 한 주관적 판단

등급: - (위험이) 확실한

- (위험이) 있을 것 같은

- (위험이) 있을 수 있는

- (위험이) 있을 것 같지 않은

- 83 -

Appendix 3. Clinical Diagnostic Criteria for Dysphagia and Aspiration of MASA

Swallowing impairment(dysphagia)

Normal: No detected abnormalities of swallowing

Possible:

Delay, disorder, and/ or weakness of at least one of the components of

swallowing, adversely affecting bolus management and delivery, and thought to

mildly increase the risk of swallowing impairment and aspiration

Probable: Delay, disorder, and/ or weakness of several components of swallowing,

moderately increasing the risk of swallowing impairment and aspiration

Definite:

Delay, disorder, and/ or weakness of several(usually five) items from clinical

assessment, substantially increasing the risk of swallowing impairment and

aspiration(may include observation of respiratory distress, choking, coughing,

color change, wet-hoarse vocal quality, or delayed oral or pharyngeal transit

times)

Aspiration

Unlikely: No detected abnormalities of swallowing

Possible:

Delay, disorder, and/ or weakness of at least one of the components of

swallowing, adversely affecting bolus management and delivery, suggesting mild

risk of airway entry of the bolus

Probable: Delay, disorder, and/ or weakness of several components of swallowing,

suggesting moderate risk of airway entry of bolus

Definite:

Delay, disorder, and/ or weakness of several items(usually five or more)

suggesting considerable risk of airway compromise(may include direct

observation of respiratory distress, choking, cyanosis, gurgling, or incomplete

expectoration)

- 84 -

Appendix 4. 연하장애와 기도흡인에 한 임상적(주관적) 진단기준

삼킴 손상(연하장애)

정 상: 비정상적 모습이 관찰되지 않음

있을 것 같은:

삼킴 관련 요소들 중 적어도 하나 이상에서 지연, 장애, 약화를

보여, 음식덩이 관리와 운반에 불리한 영향을 미치며, 삼킴

장애와 기도흡인의 위험성을 경미하게 증가시킬 것으로 생각됨

있을 수 있는: 삼킴 관련 요소들 중 여러 가지의 지연, 장애, 약화를 보여,

삼킴 장애와 기도흡인의 위험성을 중등도로 증가시킴

확 실 한:

임상적 평가로부터의 여러 항목들의(일반적으로 5 개) 지연,

장애, 약화가 삼킴 장애와 기도흡인의 위험성을 현저히

증가시킴(호흡 곤란, 질식, 기침, 얼굴색 변화, 젖은-쉰 목소리,

구강통과시간 또는 인두통과시간의 지연 등이 포함될 수 있음)

기도흡인

정 상: 비정상적 모습이 관찰되지 않음

있을 것 같은:

삼킴 관련 요소들 중 적어도 하나 이상에서 지연, 장애, 약화를

보여, 음식덩이 관리와 운반에 불리한 영향을 미치며, 음식덩이

가 기도로 진입할 수 있는 위험성이 경미함을 암시

있을 수 있는: 삼킴 관련 요소들 중 여러 가지의 지연, 장애, 약화를 보여,

음식덩이가 기도로 진입할 수 있는 위험성이 중등도임을 암시

확 실 한:

여러 항목들의(일반적으로 5 개 또는 그 이상) 지연, 장애,

약화가 기도 진입의 위험성이 매우 높음을 암시(호흡곤란, 질식,

청색증, 목구멍 울림, 불완전한 가래 밷음이 직접적으로 관찰될

수도 있음)

- 85 -

Appendix 5. K-MASA 내용 타당도 확인을 위한 설문 조사

한국어판 Mann Assessment of Swallowoing Assessment(K-MASA)의 내용 타당도

설문조사

안녕하십니까?

저는 연세대학교 대학원 작업치료학과 박사과정에 재학중인 대학원생입니다. 본 설문은

연하장애 환자의 삼킴 기능을 임상적으로 평가하는 도구에 포함된 항목들의 타당도를

확인하려는 것으로 전문가들의 의견을 듣고자 합니다. 설문 조사 결과는 연구 목적으로만

사용될 것이며, 응답하신 내용에 대해서는 비밀이 보장됨을 약속드립니다.

귀한 시간을 내어 설문에 응하여 주셔서 감사드립니다.

- 86 -

Ⅰ. 다음은 귀하의 일반적인 사항에 관한 질문입니다. 질문을 읽으시고 해당하는 번호에 “√” 표시를 하거나 알맞은 말을 적어주십시오.

1. 귀하의 직업은?

① 임상 작업치료사 ② 작업치료 또는 관련학과 학교수 ③ 기타( )

2. 귀하의 소속 기관은? (임상 작업치료사의 경우만 기재)

① 학병원 ② 종합병원 ③ 재활전문병원 ④ 요양병원 ⑤ 복지관 ⑥ 기타( )

3. 귀하의 연령은? 만( )세

4. 귀하의 성별은?

① 남 ② 여

5. 귀하의 연하재활치료 경력은? ( )년

6. 귀하의 최종학력은?

① 전문학사 ② 학사 ③ 석사 ④ 박사

- 87 -

Ⅱ. 다음은 검사도구의 내용타당도에 관한 질문입니다. 첨부된 K-MASA 검사도구를 보고

답변하여 주십시오.

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

1 각성 수준

환경 및 자신에

한 일반적인

인식부족,

자극에 한

무감각, 생각이나

주의 집중에

어려움을 보임

- 말, 움직임, 통증에 한

환자의 반응을 관찰하고

평가한다.

- 의사 또는 간호사로부터

받은 관련 정보를 포함할

수 있다.

2 협조

환자는 주의를

기울일 수

있으며 활동

내에서

상호작용할 수

있음

- 환자의 주의를 끌어

의사소통이나 활동을

시도한다.

3 청각적 이해

기본적인 언어적

의사소통을

이해할 수 있는

능력

- 환자를 특별한 형식 없이

화에 참여시킨다;

- 1-2 단계의 지시 따르기를

수행시킨다.

- 수행하기 쉬운 지시와

수행하기 어려운 지시

모두를 사용한다.

4 호흡 환자의 호흡기계

/ 폐의 상태

- 환자의 호흡기계 상태에

관해 의료진, 물리치료사

혹은 간호사 등에게

문의한다*

*주: 환자의 활동 수준에

주목한다

- 88 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

5

삼킴에

한

호흡율

호흡과 삼킴의

협응

- 휴식 시 호흡률을

관찰한다.

- 호흡 방식을

관찰한다(비강 / 구강).

- 흡기 / 호기와 관련된 침

삼킴 시기를 관찰한다.

- 삼킴 후 호흡으로의 복귀

양상을 주목, 침을 삼킨

후 호기로 돌아오는지

여부를 관찰한다.

- (기침을 할 경우), 삼킴과

관련된 기침 시기를

관찰한다.

- 환자에게 입을 다물게하고

호흡을 하다가, 편안하게

호흡을 멈추게 한다:

시간을 기록한다.

6 실어증

언어기능 손상이

다양하게

나타남: 말하기,

듣기, 읽기, 쓰기

- 환자의 구어적 표현을

특별한 형식 없이

평가한다. - 본 항목의

채점을 위해 ‘청각적 이해’

항목의 결과를 함께

사용한다.

- 소리, 단어, 수열 반복하기

- 사물, 숫자, 신체 부위

이름 기

- 간단한 질문에 답하기, 예

/ 아니오

- 기능적 이름 기

- 89 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

7

협동

운동

장애

의지적으로

말하기 위해

말과 관련된

근육의 자세를

잡거나 움직임을

차례 로

배열하는 능력의

손상. 반사적으로

또는 자연스럽게

나오는

행동에서는 이

근육들의 약화,

속도 저하 또는

협응 장애가

동반되지 않음

- ‘실어증’ 항목 평가와 같이

형식에 구애 받지 않고

평가한다.

- 음절의 길이를 증가시킨

구를 반복시키거나, 지시에

따른 다양한 구강의

움직임의 수행을 포함한다.

- 정확성, 민첩성 그리고

모방에 의한 움직임과

자연스러운 상황에서의

움직임을 기록한다.

8 조음

장애

말과 관련된

근육의 조절

장애가 특징인

발음장애; 말과

관련된 근육의

마비, 약화, 또는

협동 장애를

포함

- 특별한 형식 없이 평가한다.

- 길이를 증가시키는 발음

과제들을 포함한다; 문장

반복, 읽기, 독백. 화에

참여시킨다.

- 5 까지 세어보도록 한다;

속삭이듯이 말해보게 하고,

점차로 소리를 키워보도록

한다.

- 상반운동 반복률*을 사용할

수 있다.

*주: 빠른 교차음의 연속을

얼마나 빠르게 정확하게

하는지 평가하는 방법. 예)

푸-투-쿠를 반복

9 침 침을 관리할 수

있는 능력

- 침을 어떻게 관리하는지

관찰한다.

- 입 옆으로 침이 새어

나오는지, 입 양끝이

젖어있는지 확인한다.

- 일과시간 중에, 밤에 또는

옆으로 누워있을 때 과도한

침이 새어나온 적이 있는지

물어본다.

- 90 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

10 입술

다물기

입술의 움직임과

닫힘을 조절할

수 있는 능력

- 휴식 시 입술을 관찰한다.

- 입술 가장자리의 긴장도를

확인한다.

- 환자에게 ‘이’ 발음을

하면서 입술을 넓게

벌리라고 요청하고, ‘우’

발음을 하면서 입술을

둥글게 모으라고 요청한다.

- 두 모음간의 입술 움직임을

번갈아 가며 하라고

요청한다.

- 앞에서 사용한 소리를

반복하게 하고 언어 과제를

수행하는 동안 양 입술

기능을 관찰한다.

- 빈 수저를 물고 입술을

다무는 능력을 관찰한다.

- 볼에 바람을 불어넣고

입술을 다문 채로

유지하도록 요청한다.

11 혀의

움직임

혀의 앞쪽과

뒤쪽에서의

가동성

혀의 앞쪽

혀 내밀기- 혀를 최 한

앞으로 내밀었다 뒤로 당기게

한다.

바깥쪽으로 움직이기- 혀로

입의 양쪽 모서리를 건드리게

한 후, 이를 반복하게 한다.

혀로 구강 내 좌우 바깥쪽 볼

고랑을 훑어보도록 한다.

위로 올리기- 입을 크게 벌린

상태에서, 혀끝을

치조능선까지 올려보게 한다.

이러한 방법으로 위로

올리기와 아래로 내리기를

반복시킨다.

혀의 뒤쪽

위로 올리기- 혀의 뒤쪽을

들어 올려 구개에 닿게 하고,

그 자세를 유지 시킨다.

- 91 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

12 혀의

근력

저항 과제에

한 혀의 양쪽

근력

- 환자에게 설압자 또는

장갑을 낀 손가락에

항하여 바깥쪽으로

밀도록 한다.

- 환자에게 설압자 또는

장갑을 낀 손가락에

항하여 앞쪽으로 밀도록

한다.

- 환자에게 혀를 위쪽과

아래쪽으로 밀어보도록

한다.

- 환자에게 설압자 또는

장갑을 낀 손가락에

항하여 혀의 뒤쪽을

위로 올려보도록 요청한다.

- 저항에 한 긴장도와

근력을 확인한다.

13 혀의

협응

순차적인 반복

활동 또는 말을

하는 동안 혀의

움직임을 조절할

수 있는 능력

- 입술 주변을 핥아보도록

요청한다; 느리게 그리고

빠르게 입술의 모든 부분을

건드리게 한다.

- 혀 끝 치조음절인 ‘타’를

빠르게 반복시킨다.

- 혀 끝 치조 자음을

포함하는 문장을

반복시킨다(예: 타잔이

타조를 타고 달린다.

- 연구개 음절인 ‘카’를

빠르게 반복하라고 요청한다.

- 연구개 자음을 포함하는

문장을 반복시킨다(예:

카메라 케이스가 깨끗하다).

- 92 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

14 구강

준비

음식을 잘게

부수고, 침과

섞어, 삼킬

준비가 된

응집력 있는

음식덩이를

형성하는 능력

- 먹거나 씹는 동안 환자를

관찰한다.

- 삼키기 전에 음식덩이가

어떻게 준비되었는지

보여달라고 한다.

- 구강으로부터의 소실,

음식덩이의 위치, 구강 내

퍼짐, 바깥쪽 또는 앞쪽

고랑 내로 음식물이

빠져나갔는지 확인한다.

- 씹는 동작과 피로감을

관찰한다.

15 구역

반사

해로운 자극에

한 반응으로

유발되는 반사적

운동 반응. 10 번

뇌신경에 의한

표면의 촉각

수용기와 구심성

정보 전달의

반응을 평가

- 00 규격의 후두경을

사용하여(차갑게 해서

제공하는 것은 선택사항),

혀의 바닥부위 또는 뒤쪽

인두 벽을 건드린다.

- 인두벽 또는 연구개의

수축을 확인한다.

16 입천장 반사작용과

말하기에서

연구개의 기능

- ‘아’ 소리를 강하게 몇

초간 지속하라고 요청한다.

- ‘아’ 소리를 여러 번

반복하라고 요청한다.

- 입천장이 위로 올라가는지

확인한다.

- 이전에 시행한 말하기

과제에서 과다한 콧소리가

들리는지 관찰한다.

- 입천장 반사(palatal

reflex, 차가운 후두경을

경구개와 연구개가 만나는

지점에 가져다 댄다)를

확인한다.

- 93 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

17 음식덩

이 제거

구강 내에서

음식덩이를

효율적으로

움직이는 능력

- 환자가 음식덩이를 먹고

삼키는 것을 관찰한다.

- 삼킴 후에 구강 내

잔여물을 확인한다.

18 구강

통과

혀의 움직임이

시작되었을

때부터

음식덩이의

앞부분이 혀의

바닥을 지나

아래턱뼈의

아래쪽 모서리에

도달할 때까지

소요되는 시간.

임상적 측정에서,

이 기간은 혀의

움직임이

시작되었을

때부터 목뿔뼈

및 후두의

상승이 시작될

때까지의 시간을

측정하여야 함

따라서 시간

측정은 혀의

움직임이

시작되었을

때부터 인두

삼킴이 시작될

때까지의 시간을

추정한 것임

정확한 구강

통과시간을

측정할 수는

없음

- 임상가는 손 촉진

방법(Logemann, 1983)에

따라 손을 환자의 턱

아래에 손가락을 벌려

가져다댄다.

- 살짝 가져다 기만 한다.

- 환자에게 삼키도록

요청한다.

- 혀의 움직임이 시작될

때부터 목뿔뼈와 후두의

상승이 시작될 때까지의

시간을 측정한다(인두 삼킴

시작의 정상 시간은 약

1 초이다).

- 94 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

19 기침

반사

자극물에 한

반응으로

나타나는 반사적

기침

- 반사적 기침의 효율성에

한 정보는 물리치료사

또는 다른 관련 전문가

또는 간호사들과 함께

평가되어야 한다.

- 검사 도중에 나타나는

환자의 반사적 기침을

관찰한다.

- 기침은 호흡치료사 또는

물리치료사와 함께

이끌어낼 수도 있다.

20 자발적

기침

지시에 따른

기침 반응

- 가능한 최 한 세게

기침을 해보도록 요청한다.

- 기침의 힘과 명확성을

관찰한다.

21 목소리

목소리의 질에

특히 초점을

맞추어 후두의

기능을 평가

- ‘아’ 소리를 최 한 길게

내 보도록 요청한다.

- 음계를 위, 아래로

조절해보라고 요청한다.

- ‘스’와 ‘즈’ 발음을 길게 내

보라고 요청한다.

- 발음의 명료함, 음의 고저,

일시적인 발성일탈, 쉰

목소리, 고르지 않은 진행,

음량 조절이 안됨,

목소리가 악화되는지 등을

관찰한다.

22 기관

절개관

폐의 환기를

보조하고, 기관

기관지 분비물을

기구로 빨아내는

것을 용이하게

하고, 기도

막힘을 예방하기

위한 기관절개관

- 기관절개관의 유무를

관찰한다; 기관 절개관

삽입의 이유를 확인한다. - 정보는 호흡기 의사,

의료진, 물리치료사 또는

간호사로부터 얻을 수도

있다.

- 95 -

연번 평가

항목 개 요 과 제

적합 여부 부적합

사유

매우

적합적합 보통 부적합

매우

부적합

23 인두기

삼킴이 유발되었

을 때부터 음식

덩이가 윤상인두

괄약근을 통과할

때까지 인두기능

의 온전함.

이는 임상적으로

후두복합체의 움

직임으로 확인됨

- 손 촉진 방법(Logemann,

1983)을 이용하여

목뿔뼈와 후두의 움직임을

관찰한다.

- 운동의 매끄러움과 최 로

올라간 지점을 확인한다.

- 삼킨 후, 환자에게 몇 초간

‘아’ 소리를 내도록 한다.

목소리의 질을 확인한다.

- 삼킨 후에 숨을 헐떡이게

한 후, 소리를 내도록

요청한다. 목소리의 질을

확인한다.

- 고개를 왼쪽 또는

오른쪽으로 돌리게 한 후,

각 자세에서 소리를

내도록 요청한다. 목소리의

질을 확인한다.

- 턱을 위로 들고 소리를

내도록 요청한다. 목소리의

질을 확인한다.

24 인두

반응

인두 영역에서의

음식덩이의 조절,

그리고

물질의 정체에

한 반응과

조절

- 삼킴 후에 목소리의 질과

기침을 관찰한다.

- 다른 평가 과제들과 함께

시행되어야 한다.

- 귀한 시간을 내어주셔서 감사합니다^^ -

- 96 -

Appendix 6. Videofluoroscopic Dysphagia Scale

Factor Coded value Score

Lip closure Intact 0

Inadequate 2

None 4

Bolus formation Intact 0

Inadequate 3

None 6

Mastication Intact 0

Inadequate 4

None 8

Apraxia None 0

Mild 1.5

Moderate 3

Severe 4.5

Tongue to palate contact Intact 0

Inadequate 5

None 10

Premature bolus loss None 0

<10% 1.5

10-50% 3

>50% 4.5

Oral transit time ≤1.5s 0

>1.5s 3

Triggering of pharyngeal swallow Normal 0

Delayed 4.5

Vallecular residue None 0

<10% 2

10-50% 4

>50% 6

Laryngeal elevation Normal 0

Impaired 9

Pyriform sinus residue None 0

<10% 4.5

10-50% 9

>50% 13.5

Coating of pharyngeal wall No 0

Yes 9

Pharyngeal transit time ≤1.0s 0

>1.0s 6

Aspiration None 0

Supraglottic penetration 6

Subglottic aspiration 12

Total 100

- 97 -