ORIGINAL RESEARCH| Volume 102, ISSUE 12, P2343-2352.e3, December 2021

Status Of Dysphagia After Ischemic Stroke: A Korean Nationwide Study

Published:August 02, 2021DOI:


      • We enrolled 6000 patients with ischemic stroke from a nationwide prospective cohort.
      • The incidence of dysphagia was 32.3% (n=1940) at 7 days after ischemic stroke.
      • At the time of discharge, 80.5% (n=1561) of the patients still had dysphagia.
      • Age, body mass index, and premorbid disabilities contribute to poststroke dysphagia.



      To identify the incidence of dysphagia after ischemic stroke and determine factors affecting the presence of dysphagia.


      Retrospective case-control study. This was an interim analysis of a prospective multicenter Korean stroke cohort.


      Acute care university hospitals.


      Patients (N=6000) with first-ever acute ischemic stroke. Patients were divided into 2 groups according to the presence or absence of dysphagia confirmed at 7 days after onset using the American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA-NOMS) scale, which was determined after conducting screening or standardized tests.


      Not applicable.

      Main Outcome Measures

      Age at stroke onset, body mass index (BMI), premorbid modified Rankin Scale (mRS), brainstem lesions, National Institutes of Health Stroke Scale (NIHSS), poststroke mRS, and ASHA-NOMS swallowing level at poststroke day 7 were evaluated.


      Among patients with ischemic stroke, 32.3% (n=1940) had dysphagia at 7 days after stroke onset. At discharge, 80.5% (n=1561) still had dysphagia. The prediction model for the presence of dysphagia identified age at onset, underweight (BMI <18.5 kg/m2), premorbid mRS, brainstem lesions, and NIHSS as independent predictors. The odds ratio (OR) for the presence of dysphagia significantly increased with underweight (OR, 1.6684; 95% confidence interval [CI], 1.27-2.20), increased age at onset (OR, 1.0318; 95% CI, 1.03-1.04), premorbid mRS (OR, 1.1832; 95% CI, 1.13-1.24), brainstem lesions (OR, 1.6494; 95% CI, 1.39-1.96), and NIHSS (OR, 1.2073; 95% CI, 1.19-1.23).


      The incidence of dysphagia after ischemic stroke was 32.3%. The prediction model for the presence of dysphagia identified age, low BMI, premorbid disabilities, brainstem lesions, and NIHSS as predictive factors.


      List of abbreviations:

      ASHA-NOMS (American Speech-Language-Hearing Association National Outcomes Measurement System), BMI (body mass index), CI (confidence interval), FEES (fiberoptic endoscopic evaluation of swallowing test), FMA (Fugl-Meyer assessment), KOSCO (Korean Stroke Cohort for Functioning and Rehabilitation), MMSE (Mini-Mental State Examination), mRS (modified Rankin Scale), NIHSS (National Institutes of Health Stroke Scale), OR (odds ratio), VFSS (videofluoroscopic swallowing study)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mann G
        • Hankey GJ
        • Cameron DJS.
        Swallowing function after stroke: prognosis and prognostic factors at 6 months.
        Stroke. 1999; 30: 744-748
        • Smithard DG
        • O'Neill PA
        • England RE
        • et al.
        The natural history of dysphagia following a stroke.
        Dysphagia. 1997; 12: 188-193
        • Dávalos A
        • Ricart W
        • Gonzalez-Huix F
        • Soler S
        • Marrugat J
        • Molins A
        • et al.
        Effect of malnutrition after acute stroke on clinical outcome.
        Stroke. 1996; 27: 1028-1032
        • Marik PE
        • Kaplan DJC.
        Aspiration pneumonia and dysphagia in the elderly.
        Chest. 2003; 124: 328-336
        • Martino R
        • Pron G
        • Diamant N.
        Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines.
        Dysphagia. 2000; 15: 19-30
        • Martino R
        • Foley N
        • Bhogal S
        • Diamant N
        • Speechley M
        • Teasell RJs
        Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.
        Sroke. 2005; 36: 2756-2763
        • Arnold M
        • Liesirova K
        • Broeg-Morvay A
        • Meisterernst J
        • Schlager M
        • Mono M-L
        • et al.
        Dysphagia in acute stroke: incidence, burden and impact on clinical outcome.
        PLoS One. 2016; 1e0148424
        • Galovic M
        • Stauber AJ
        • Leisi N
        • et al.
        Development and validation of a prognostic model of swallowing recovery and enteral tube feeding after ischemic stroke.
        JAMA Neurol. 2019; 76: 561-570
        • Han TR
        • Paik N-J
        • Park J-W
        • Kwon BSJD
        The prediction of persistent dysphagia beyond six months after stroke.
        Dysphagia. 2008; 23: 59-64
        • Lee WH
        • Lim MH
        • Seo HG
        • Seong MY
        • Oh B-M
        • Kim SJS.
        Development of a novel prognostic model to predict 6-month swallowing recovery after ischemic stroke.
        Stroke. 2020; 51: 440-448
        • Chang WH
        • Sohn MK
        • Lee J
        • et al.
        Korean Stroke Cohort for functioning and rehabilitation (KOSCO): study rationale and protocol of a multi-centre prospective cohort study.
        BMC neurol. 2015; 15: 1-7
        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chron Dis. 1987; 40: 373-383
      1. Bernardini J, Callen S, Fried L, Piraino B. Inter-rater reliability and annual rescoring of the Charlson comorbidity index. Proceedings of the advances in peritoneal dialysis Conference on peritoneal dialysis; 2004.

        • Quinn TJ
        • Taylor-Rowan M
        • Coyte A
        • et al.
        Pre-stroke modified Rankin scale: evaluation of validity, prognostic accuracy, and association with treatment.
        Front Neurol. 2017; 8: 275
        • Burn J.
        Reliability of the modified Rankin Scale.
        Stroke. 1992; 23: 438
        • Young FB
        • Weir CJ
        • Lees KR.
        Comparison of the National Institutes of Health Stroke Scale with disability outcome measures in acute stroke trials.
        Stroke. 2005; 36: 2187-2192
        • Fugl-Meyer AR
        • Jääskö L
        • Leyman I
        • Olsson S
        • Steglind S.
        The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • System NAS-L-HANOM
        Adult Speech-Language Pathology User's guide.
        National Center for Evidence-Based Practice in Communication Disorders, 2003
        • Tohara H
        • Saitoh E
        • Mays KA
        • Kuhlemeier K
        • Palmer JB.
        Three tests for predicting aspiration without videofluorography.
        Dysphagia. 2003; 18: 126-134
        • Kirby DF
        • DeLegge MH
        • Fleming CR.
        American Gastroenterological Association technical review on tube feeding for enteral nutrition.
        Gastroenterology. 1995; 108: 1282-1301
        • Stroud M
        • Duncan H
        • Nightingale JJG.
        Guidelines for enteral feeding in adult hospital patients.
        Gut. 2003; 52: vii1-vii12
        • Wirth R
        • Smoliner C
        • Jäger M
        • et al.
        Guideline clinical nutrition in patients with stroke.
        Exp Transl Stroke Med. 2013; 5: 1-11
        • Kim J
        • Oh B-M
        • Kim JY
        • Lee GJ
        • Lee SA
        • Han TR.
        Validation of the videofluoroscopic dysphagia scale in various etiologies.
        Dysphagia. 2014; 29: 438-443
        • De Stefano A
        • Dispenza F
        • Kulamarva G
        • et al.
        Predictive factors of severity and persistence of oropharyngeal dysphagia in sub-acute stroke.
        Eur Arch Otorhinolaryngol. 2021; 278: 741-748
        • Dungan S
        • Gregorio D
        • Abrahams T
        • et al.
        Comparative Validity of the American Speech-Language-Hearing Association's National Outcomes Measurement System, Functional Oral Intake Scale, and G-Codes to Mann Assessment of Swallowing Ability Scores for Dysphagia.
        Am J Speech Lang Pathol. 2019; 28: 424-429
      2. World Health Organization. Europe Nutrition-Body Mass Index. Available at: Accessed April 25, 2021.

        • Jang SY
        • Shin Y-I
        • Kim DY
        • et al.
        Effect of obesity on functional outcomes at 6 months post-stroke among elderly Koreans: a prospective multicentre study.
        BMJ Open. 2015; 5e008712
        • González-Fernández M
        • Ottenstein L
        • Atanelov L
        • Christian AB.
        Dysphagia after stroke: an overview.
        Curr Phys Med Rehabil Rep. 2013; 1: 187-196
        • Ho C-H
        • Lin W-C
        • Hsu Y-F
        • Lee I-H
        • Hung Y-C.
        One-year risk of pneumonia and mortality in patients with poststroke dysphagia: a nationwide population-based study.
        J Stroke Cerebrovasc Dis. 2018; 27: 1311-1317
        • Bailey K
        • Ferro-Luzzi A.
        Use of body mass index of adults in assessing individual and community nutritional status.
        Bull World Health Organ. 1995; 73: 673
        • Campillo B
        • Paillaud E
        • Uzan I
        • et al.
        Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters.
        Clin Nutr. 2004; 23: 551-559
        • Marini AC
        • Pimentel GD.
        Is body weight or muscle strength correlated with the Malnutrition Inflammation Score (MIS)? A cross-sectional study in hemodialysis patients.
        Clin Nutr ESPEN. 2019; 33: 276-278
        • Nasimi N
        • Dabbaghmanesh MH
        • Sohrabi Z.
        Nutritional status and body fat mass: Determinants of sarcopenia in community-dwelling older adults.
        Exp Gerontol. 2019; 122: 67-73
        • Sugawara K
        • Yamashita H
        • Okumura Y
        • et al.
        Relationships among body composition, muscle strength, and sarcopenia in esophageal squamous cell carcinoma patients.
        Support Care Cancer. 2020; 28: 2797-2803
        • Costa TMdRL
        • Costa FM
        • Moreira CA
        • Rabelo LM
        • Boguszewski CL
        • Borba VZC.
        Sarcopenia in COPD: relationship with COPD severity and prognosis.
        J Bras Pneumol. 2015; 41: 415-421
        • Kim H
        • Hirano H
        • Edahiro A
        • et al.
        Sarcopenia: prevalence and associated factors based on different suggested definitions in community-dwelling older adults.
        Geriatr Gerontol Int. 2016; 16: 110-122
        • Scrutinio D
        • Lanzillo B
        • Guida P
        • Passantino A
        • Spaccavento S
        • Battista P.
        Association between malnutrition and outcomes in patients with severe ischemic stroke undergoing rehabilitation.
        Arch Phys Med Rehabil. 2020; 101: 852-860
        • Aliasghari F
        • Izadi A
        • Khalili M
        • Farhoudi M
        • Ahmadiyan S
        • Deljavan R.
        Impact of premorbid malnutrition and dysphagia on ischemic stroke outcome in elderly patients: a community-based study.
        J Am Coll Nutr. 2019; 38: 318-326
        • Carnaby G
        • Sia I
        • Crary M.
        associations between spontaneous swallowing frequency at admission, dysphagia, and stroke-related outcomes in acute care.
        Arch Phys Med Rehabil. 2019; 100: 1283-1288
        • Jeyaseelan RD
        • Vargo MM
        • Chae J
        National Institutes of Health Stroke Scale (NIHSS) as an early predictor of poststroke dysphagia.
        PM&R. 2015; 7: 593-598
        • Daniels SK
        • Pathak S
        • Mukhi SV
        • Stach CB
        • Morgan RO
        • Anderson JA.
        The relationship between lesion localization and dysphagia in acute stroke.
        Dysphagia. 2017; 32: 777-784
        • Miller AJ
        • Kaatzke-McDonald M
        The neuroscientific principles of swallowing and dysphagia.
        Advances in Speech Language Pathology. 2000; 2: 155-156
        • Meng NH
        • Wang TG
        • Lien IN.
        Dysphagia in patients with brainstem stroke: incidence and outcome.
        Am J Phys Med Rehabil. 2000; 79: 170-175
        • Shimizu A
        • Maeda K
        • Koyanagi Y
        • Kayashita J
        • Fujishima I
        • Mori N.
        The global leadership initiative on malnutrition–defined malnutrition predicts prognosis in persons with stroke-related dysphagia.
        JAMDA. 2019; 20: 1628-1633
        • Chen N
        • Li Y
        • Fang J
        • Lu Q
        • He L.
        Risk factors for malnutrition in stroke patients: a meta-analysis.
        Clin Nutr. 2019; 38: 127-135
        • Kondrup J
        • Allison SP
        • Elia M
        • Vellas B
        • Plauth M.
        ESPEN guidelines for nutrition screening 2002.
        Clin Nutr. 2003; 22: 415-421
        • Rubenstein LZ
        • Harker JO
        • Salvà A
        • Guigoz Y
        • Vellas B.
        Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF).
        J Gerontol A Biol Sci Med Sci. 2001; 56 (M366-M72)
        • Stratton RJ
        • Hackston A
        • Longmore D
        • et al.
        Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’(‘MUST’) for adults.
        BJN. 2004; 92: 799-808
        • Cederholm T
        • Bosaeus I
        • Barazzoni R
        • et al.
        Diagnostic criteria for malnutrition–an ESPEN consensus statement.
        Clin Nutr. 2015; 34: 335-340
        • Cederholm T
        • Jensen G
        • Correia M
        • et al.
        GLIM criteria for the diagnosis of malnutrition–a consensus report from the global clinical nutrition community.
        J Cachexia Sarcopenia Muscle. 2019; 10: 207-217
        • Sremanakova J
        • Burden S
        • Kama Y
        • et al.
        An observational cohort study investigating risk of malnutrition using the malnutrition universal screening tool in patients with stroke.
        J Stroke Cerebrovasc Dis. 2019; 28104405
        • Geeganage C
        • Beavan J
        • Ellender S
        • Bath PM.
        Interventions for dysphagia and nutritional support in acute and subacute stroke.
        Cochrane Database Syst Rev. 2012; 10CD000323
        • Eltringham SA
        • Kilner K
        • Gee M
        • et al.
        Impact of dysphagia assessment and management on risk of stroke-associated pneumonia: a systematic review.
        Cerebrovasc Dis. 2018; 46: 97-105
        • Gomes F
        • Emery PW
        • Weekes CE.
        Risk of malnutrition is an independent predictor of mortality, length of hospital stay, and hospitalization costs in stroke patients.
        J Stroke Cerebrovasc Dis. 2016; 25: 799-806
        • Teh W-H
        • Smith CJ
        • Barlas RS
        • et al.
        Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome.
        Acta Psychiatr Scand. 2018; 138: 293-300
        • Kim DH
        • Choi KH
        • Kim HM
        • et al.
        Inter-rater reliability of videofluoroscopic dysphagia scale.
        Ann Rehabil Med. 2012; 36: 791
        • Leslie P
        • Smithard DG.
        Is dysphagia under diagnosed or is normal swallowing more variable than we think? Reported swallowing problems in people aged 18-65 years.
        Dysphagia. 2020; : 1-9