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Psychometric assessment and validation of the dysphagia severity rating scale in stroke patients

Everton, Lisa F.; Benfield, Jacqueline K.; Hedstrom, Amanda; Wilkinson, Gwenllian; Michou, Emilia; England, Timothy J.; Dziewas, Rainer; Bath, Philip M.; Hamdy, Shaheen


Lisa F. Everton

Jacqueline K. Benfield

Gwenllian Wilkinson

Emilia Michou

Rainer Dziewas

Stroke Association Professor of Stroke Medicine

Shaheen Hamdy


Post stroke dysphagia (PSD) is common and associated with poor outcome. The Dysphagia Severity Rating Scale (DSRS), which grades how severe dysphagia is based on fluid and diet modification and supervision requirements for feeding, is used for clinical research but has limited published validation information. Multiple approaches were taken to validate the DSRS, including concurrent- and predictive criterion validity, internal consistency, inter- and intra-rater reliability and sensitivity to change. This was done using data from four studies involving pharyngeal electrical stimulation in acute stroke patients with dysphagia, an individual patient data meta-analysis and unpublished studies (NCT03499574, NCT03700853). In addition, consensual- and content validity and the Minimal Clinically Important Difference (MCID) were assessed using anonymous surveys sent to UK-based Speech and Language Therapists (SLTs). Scores for consensual validity were mostly moderate (62.5–78%) to high or excellent (89–100%) for most scenarios. All but two assessments of content validity were excellent. In concurrent criterion validity assessments, DSRS was most closely associated with measures of radiological aspiration (penetration aspiration scale, Spearman rank rs = 0.49, p [less than] 0.001) and swallowing (functional oral intake scale, FOIS, rs =−0.96, p [less than] 0.001); weaker but statistically significant associations were seen with impairment, disability and dependency. A similar pattern of relationships was seen for predictive criterion validity. Internal consistency (Cronbach’s alpha) was either “good” or “excellent”. Intra and inter-rater reliability were largely “excellent” (intraclass correlation >0.90). DSRS was sensitive to positive change during recovery (medians: 7, 4 and 1 at baseline and 2 and 13 weeks respectively) and in response to an intervention, pharyngeal electrical stimulation, in a published meta-analysis. The MCID was 1.0 and DSRS and FOIS scores may be estimated from each other. The DSRS appears to be a valid tool for grading the severity of swallowing impairment in patients with post stroke dysphagia and is appropriate for use in clinical research and clinical service delivery


Everton, L. F., Benfield, J. K., Hedstrom, A., Wilkinson, G., Michou, E., England, T. J., …Hamdy, S. (2020). Psychometric assessment and validation of the dysphagia severity rating scale in stroke patients. Scientific Reports, 10,

Journal Article Type Article
Acceptance Date Mar 30, 2020
Online Publication Date Apr 29, 2020
Publication Date Apr 29, 2020
Deposit Date Apr 30, 2020
Publicly Available Date Apr 30, 2020
Journal Scientific Reports
Print ISSN 2045-2322
Electronic ISSN 2045-2322
Publisher Nature Publishing Group
Peer Reviewed Peer Reviewed
Volume 10
Article Number 7268
Public URL
Publisher URL
Additional Information Received: 17 January 2020; Accepted: 30 March 2020; First Online: 29 April 2020; : Phagenesis Ltd funded the STEPS and PHAST-TRAC trials. P.M. Bath is Stroke Association Professor of Stroke Medicine and a NIHR Senior Investigator, and undertakes consultancy work for Phagenesis. S. Hamdy is Professor of Neurogastroenterology and a board director and CSO of Phagenesis and hold stocks/shares in the company. R. Dziewas is a Professor of Neurology: no competing interests. T. England is a Clinical Associate Professor at the University of Nottingham: no competing interests. E. Michou, L. Everton, J. Benfield, A. Hedstrom, G. Wilkinson: no competing interests.