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Rehabilitation Measures

Mann Assessment of Swallowing Ability (MASA)

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Purpose

The Mann Assessment of Swallowing Ability (MASA) is an instrument that was designed for bedside evaluations for patients referred for swallowing function assessment.

This assessment measures 24 different areas to gauge a patient’s swallowing ability, in order to make appropriate recommendations for diet and fluid intake.

 

Alertness

Cooperation

Auditory Comprehension

Respiration

Respiratory Rate (for swallow)

Dysphasia

Dyspraxia

Dysarthria

Saliva (is there drooling?)

Lip seal

Tongue movement

Tongue strength

Tongue coordination

Oral preparation

Gag

Palate

Bolus clearance

Oral Transit

Cough Reflex

Voluntary Cough

Voice

Trache

Pharyngeal phase

Pharyngeal response

Link to Instrument

Instrument Details

Acronym MASA

Area of Assessment

Swallowing

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$1600.00

Cost Description

The book with instructions is currently out of print and is listed on Amazon.com at the time of this review for $1600.

Key Descriptions

  • Described by Mann (2002), Carnaby & Crary (2014):
    ● Number of items in the instrument: 24 items
    ● The highest possible score is 200.
    ● Score: 170-200, no abnormality; 149-169, mild; 141-148, moderate; ≤140, severe.
    ● The 24 items are converted into a weighted 5 or 10 points
    ● Administration instructions: specific instructions are not accessible. Based on the other information found, all that is needed is the evaluation and a pencil.
  • The modified version for cancer patients (MASA-C) includes 15 of the original 24 items in the MASA with the addition of nine cancer-specific items to include neck palpation, mouth opening, taste, smell, current diet, oral mucous membrane, and weight loss. Items from the original MASA that were eliminated included alertness, cooperation, respiratory rate, gag, and cough reflex. The total maximum score for the MASA-C is 200 points (Carnaby & Crary, 2014).
    ● Number of items in the instrument: 24 items (see above for breakdown)
    ● The highest possible score is 200.
    ● Score: 184-200 = no abnormality; 174-183 = mild; 164-173 = moderate; ≤163 = severe.
    ● The items are weighted similarly to the original MASA
    ● Administration instructions: specific instructions are not accessible. Based on the other information found, all that is needed is the evaluation and a pencil.

Number of Items

24

Equipment Required

  • User Manual with instrument

Time to Administer

20 minutes

Required Training

Reading an Article/Manual

Required Training Description

Typically performed by SLP, nursing or physicians

Age Ranges

Adult

18 - 64

years

Older Adults

+

years

Instrument Reviewers

Jason Hugentobler,PT, DPT, SCS, CSCS

Melissa Mattner, MS, OTR/L

Victoria Montoya, MS, MPS, PA(ASCP)

Body Part

Head
Neck

ICF Domain

Body Function

Measurement Domain

General Health

Considerations

  • At this time, the book with the original validity and reliability study information is out of print and only accessible in a relatively small amount of university libraries. The cost to purchase the book on Amazon.com has increased from approximately $800 to $1600 in a matter of weeks.
  • A possible cause for concern is the method of publication of the original MASA. Giselle Mann’s scale was published in the form of a standalone book, and while there are a few, there is a lack of peer-reviewed journal articles addressing the reliability/validity of the original MASA. 
  • No way to access PDF versions of the MMASA or MASA-C were found.
  • Some of the psychometrics, particularly SEM and MDC, were limited in the literature, and further peer-reviewed validation might be indicated
  • An additional consideration is possible variation in scores based on clinical training and experience levels of individuals administering the test.
  • A number of different providers are capable of administering the test, including but not limited to: speech pathologists, nurses and physicians.

Stroke

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Cut-Off Scores

Acute Stroke: (Mann, 2002; n = 128; Mann, Hankey, & Cameron, 2000 ; n= 128 ; mean age = 71 ; assessed <7 days since symptom onset)

  • < 180 indicates a diagnosis of dysphagia (sensitivity 71%)
  • > 180 indicates a patient who is nondysphagic (specificity 72%)

 

Acute Stroke: (Antonios et al, 2010;n=150; mean age = 64.5 (14.4) years;  assessed mean hours post stroke 88.03 (56.30) < 94 was the optimal cut point, for the identification of dysphagia

  • MMASA administered by the first neurologist (N1) identified dysphagia in 57 (38%; 95% CI: 30.6-46) patients, whereas the MMASA administered by the second neurologist (N2) identified dysphagia in 55 (36.7%, 95% CI: 29-45) patients.
  • With use of the original MASA, 36.2% demonstrated dysphagia.

Normative Data

Acute Stroke: (Mann, 2002)

  • Nondysphagic patients= mean score 185 (SD 10.9); median score 187 (range 159-200)
  • Dysphagic patients= mean score 163.8 (SD 22); median score 166 (range 105-199)
    • Mild dysphagia mean score = 173
    • Moderate dysphagia mean score = 160
    • Severe dysphagia mean score= 132

Acute Stroke: (Antonios et al., 2010).

  • Mean MASA Score for the 54 patients identified with dysphagia was 136.7 (SD:50)
  • Mild dysphagia in 21 patients with a score range = 168-177
  • Moderate dysphagia in 17 patients with a score range = 139-167
  • Severe dysphagia in 16 patients with scores = ≤138.

Interrater/Intrarater Reliability

Acute Stroke: (Mann, 2002)

Measured via agreement between two speech pathologists:

  • Excellent interrater reliability (Kappa= 0.82) for dysphagia
  • Excellent interrater reliability (Kappa= 0.75) for aspiration

Acute Stroke: (Antonios et al., 2010)

  • Excellent: Interrater agreement between the neurologists using the MMASA: k=0.76; SE=0.082

Internal Consistency

Acute Stroke: (Mann, 2002)

  • Excellent internal consistency: Standardized Cronbach's alpha = 0.9166

*Scores higher than .9 may indicate redundancy in the scale questions.

Acute Stroke, Normative Sample: (Antonios et al., 2010, n=12)

  • Excellent: Cronbach's alpha of 0.94, indicating the items are sufficiently homogeneous, with high internal consistency on each of the 12 items.

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Acute Stroke: (Mann, 2002)

  • Excellent predictive validity for identifying patients with dysphagia (Positive predictive value = 92%)

Acute Stroke: (Antonios et al., 2010.)

  • Sensitivity and specificity in the detection of dysphagia was high for the results obtained from both neurologists (sensitivity: 92% and 87%, respectively; specificity: 86.3% and 84.2%, respectively).

Content Validity

Acute Stroke: (Mann, 2002)

Content validity of the MASA was determined via a review of the literature which “confirmed that the items included in the MASA samples all the relevant clinical dimensions of acquired swallowing dysfunction” (Mann, 2002, p.16). The MASA was compared with multiple other previously validated tools to confirm that it included “all domains necessary to adequately describe normal swallowing function of an individual” (Mann, 2002, p. 16). The MASA was also determined to reflect current neurophysiological theory of swallowing control and aspects of swallowing physiology identified in the literature.

Face Validity

Acute Stroke: (Mann, 2002)

Mann (2002) reports that the MASA was originally derived from a composite of multiple non standardized clinical assessments that were being used in an acute care setting (p. 15). A panel of 15 content experts identified items that they felt should be included or not included in a clinical assessment of dysphagia and ranked the items with an ordinal score (see table below). The panel also provided comments on any modifications that were recommended, and three sections of the examination underwent minor modifications based on this input.

 

Item ranking: 1 = poor, 2 = needs major alteration, 3 = minor alterations, 4 = adequate

 

 

Feature:

Item inclusion (% of rater agreement)

% rated adequate (no modification required)

Prerequisite medical information

80

60

swallowing physiology

80

80

test swallow parameters

80

80

water swallow included

40

0

dietary information

60

40

definition of items

40

60

measurement scale

60

80

presentation

100

80

style

60

80

requires modification

60

80

Responsiveness

Acute Stroke: (Antonios et al., 2010.)

  • Evidence of dysphagia in 54 patients. Mean MASA score for patients with dysphagia was 136.7 (50); severe dysphagia (MASA≤138) was identified in 16 patients; moderate dysphasia (139-167) in 17 patients; mild dysphagia (168-177) in 21 patients.
  • MMASA administered by the first neurologist (N1) identified dysphagia in 57 (38%; 95% CI: 30.6-46) patients, whereas the MMASA administered by the second neurologist (N2) identified dysphagia in 55 (36.7%, 95% CI: 29-45) patients.
  • With use of the original MASA, 36.2% demonstrated dysphagia.

Cancer

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Cut-Off Scores

Cancer: (Carnaby & Crary, 2014; n=50; mean age= 57.6 (11.35) years; mean time post diagnosis= 35 days)

The modified MASA-C was developed for use in patients receiving radiotherapy for head and neck cancer. This patient population frequently experiences dysphagia as a side effect (Carnaby & Crary, 2014).

  • Optimal cut point to identify any dysphagia: <185 (Sensitivity of this cut point for detection of dysphagia= 83%, specificity = 96%) (Carnaby & Crary, 2014, p. 599).
  • Optimal cut point to identify presence of any aspiration: <176

Normative Data

Cancer: (Carnaby & Crary, 2014)

  • Mean MASA-C score for dysphagic patients (identified by VFE): 177 (14.01)
  • Mean MASA-C score for dysphagia severity (identified by VFE): mild=183 (9.8); moderate= 172.6 (12), severe 163.4 (8)
  • Mean MASA-C score for patients demonstrating aspiration: 167 (12.09)

Test/Retest Reliability

Cancer: (Carnaby & Crary, 2014)

  • Excellent test-retest reliability: (ICC= 0.96 [baseline] and 0.92 [posttreatment])

Interrater/Intrarater Reliability

Cancer: (Carnaby & Crary, 2014)

  • Excellent interrater reliability (ICC= 0.96)
  • Excellent intrarater reliability (ICC= 0.94)

Internal Consistency

Cancer: (Carnaby & Crary, 2014)

  • Excellent: Cronbach’s alpha = 0.94
  • High item consistency (relationship of individual exam items to overall exam score, r >0.5

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Cancer: (Carnaby & Crary, 2014)

  • Excellent predictive validity: ROC analysis- area under the curve: 0.95 (0.84-0.99)

 

Concurrent Validity

Cancer: (Carnaby & Crary, 2014)

Concurrent validity: The MASA-C was compared to:

    • Functional Assessment of Cancer Therapy- Head and Neck (FACT H&N): Adequate; r=0.488
    • Functional Oral Intake Scale (FOIS): Excellent; r=0.8295
    • Videofluoroscopic assessment (VFE) score: Poor; r= -0.3901
    • Original MASA: Excellent; r=0.699

Content Validity

The developers of the MASA-C, conducted a theoretical review, via previous literature, to identify specific items related to the population of head and neck cancer patients. Five expert reviewers were asked to rate the potential new items added to the MASA-C, then a field test of all items, both new and original, was performed on the first ten subjects in the study. An item analysis was used to determine the value of each new item on the revised test, then revised items were selected on the basis of correlation, with items having an individual Cronbach’s alpha of .0.85 denoting inclusion (Carnaby & Crary, 2014).

Floor/Ceiling Effects

Cancer: (Carnaby & Crary, 2014; n=50; mean age= 57.6 (11.35) years; mean time post diagnosis= 35 days)

  • No floor/ceiling effects reported at this time.

Responsiveness

Cancer: (Carnaby & Crary, 2014; n=50; mean age= 57.6 (11.35) years; mean time post diagnosis= 35 days)

  • For every 10 point rise in MASA-C score, the odds of a favorable outcome posttreatment rose by 15.49 times compared to patients not improving their MASA-C score 
  • Carnaby and Crary (2014) recommend further research to identify the MASA-C’s ability to predictively map outcomes for this population over longer time periods (p. 601).

Pulmonary Diseases

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Cut-Off Scores

Pneumonia: (Chojin et al., , 2017; n=153; mean age = 85.4 (9.9) years; females 96, males 57; length of hospital stay = 19.1 (11.9) days, administered 3 days post-admission MASA Score severity adopted from Mann (2002) for stroke patients:

  • No aspiration risk Score ≥ 170 (170-200)
  • Mild aspiration risk Score149-169
  • Moderate aspiration risk Score 141-148
  • Severe aspiration risk Score ≤ 140
  • The authors noted “we used the cut-off levels determined in acute stroke patients, but more optimal cut off levels should be identified in the future” (Chojin et al., 2017, p. 428).

Normative Data

Pneumonia (Chojin et al., , 2017):

  • Normal MASA Score ≥ 170 (170-200) - noted in 28.1% of patients in the current study
  • Abnormal Score (≤ 169) was noted in 71.9% of patients

Assessment item of the MASA

  • Abnormal respiration - 100% of patients
  • Abnormal oral transit - 86.9%
  • Abnormal tongue strength - 79.7%
  • Abnormal respiratory rate for swallowing - 79.1% (full list below)

Number of abnormality of the clinical assessment items of the Mann Assessment of Swallowing Ability.

Clinical assessment items Number of abnormality (%)

Alertness 69 (45.1)

Cooperation 95 (62.1)

Auditory comprehension 119 (77.8)

Respiration 153 (100)

Respiratory rate for swallowing 121 (79.1)

Dysphasia 83 (54.2)

Dyspraxia 41 (26.8)

Dysarthria 103 (67.3)

Saliva 34 (22.2)

Lip Seal 95 (62.1)

Tongue movement 105 (68.6)

Tongue strength 122 (79.7)

Tongue coordination 131 (85.6)

Oral preparation 86 (56.2)

Gag 116 (75.8)

Palate 87 (56.9)

Bolus clearance 85 (55.6)

Oral transit 133 (86.9)

Cough reflex 109 (71.2)

Voluntary cough 101 (66.0)

Voice 95 (62.1)

Trachea 1 (0.7)

Pharyngeal phase 103 (67.3)

Pharyngeal response 27 (17.6)

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Pneumonia (Chojin et al., , 2017)

  • ROC curve and analysis-area under the curve for MASA score severity classification and each outcome.
    • AUC 0.74 (0.67-0.82) (adequate) for in-hospital mortality (all 153 patients used)
    • AUC 0.75 (0.68-0.82) (adequate) for recurrence of pneumonia within 30 days (145 patients used)
    • AUC 0.72 (0.67-0.81)(adequate) for 6 month mortality (127 patients used)
    • AUC 0.60 (0.46-0.73) (poor) for detection of antibiotic-resistant bacteria (82 patients used)

Multivariate analysis of risk factors for each outcome:

  • MASA Score ≤ 169 and recurrence of pneumonia within 30 days has odds ratio of 36.20 (95% CI 4.17-314.67, p 0.001)
  • MASA Score ≤ 169 and 6 month mortality has odds ratio of 21.29 (95% CI 2.49-182.22, p 0.005)

Univariate analysis of risk factors for each outcome:

  • MASA Score ≤ 169 and recurrence of pneumonia within 30 days has odds ratio of 33.09 (95% CI 4.38-249.78, p 0.001)
  • MASA Score ≤ 169 and 6 month mortality has odds ratio of 16.98 (95% CI 2.22-130.10, p 0.006)

 

Concurrent Validity

Pneumonia (Chojin et al., , 2017)

  • Adequate  (r = 0.41, p < 0.0001) correlation between the MASA score and the Revised Oral Assessment Guide (ROAG) 

Older Adults and Geriatric Care

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Cut-Off Scores

Dependent Older Adults with dysphagia: (Ohira et al 2017)

The optimal MASA cut‐off values for diagnosing aspiration and pharyngeal retention were found to be 122 points and 151 points, respectively.  The MASA cut‐off value reported by Mann (170 points) showed sensitivity and specificity values of 0.90 and 0.33, respectively, and a positive likelihood ratio of 1.39.

Normative Data

Dependent Older Adults with dysphagia: (Ohira et al 2017, n=50; mean age = 84.35 ± 7.95 years, male: female ration 7:13)

 

Aspiration

Pharyngeal retention

 

+

Pvalue

+

Pvalue

 

( = 20)

( = 30)

 

( = 36)

( = 14)

 

MASA

120.15 ± 28.19

154.40 ± 24.95

<.001

133.50 ± 31.34

159.21 ± 21.80

<.01

Criterion Validity (Predictive/Concurrent)

Dependent Older Adults with dysphagia: (Ohira et al 2017)

  • Excellent: The MASA showed an AUC of 0.82 and 0.74 for predicting aspiration and pharyngeal retention, respectively. 

Bibliography

Antonios, N., Carnaby-Mann, G., Crary, M., Miller, L., Hubbard, H., Hood, K., Sanbandam, R., Xavier, A., & Silliman, S. (2010). Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: The Modified Mann Assessment of Swallowing Ability. Journal of Stroke and Cerebrovascular Disease, 19(1), 49-57. Find it on PubMed.

Carnaby, G. D., & Crary, M. A. (2014). Development and validation of a cancer-specific swallowing assessment tool: MASA-C. Supportive Care in Cancer, 22(3), 595-602. doi:Find it on PubMed.

Chojin Y, Kato T, Rikihisa M, et al. Evaluation of the Mann Assessment of Swallowing Ability in Elderly Patients with Pneumonia. Aging Dis. 2017;8(4):420–433. Published 2017 Jul 21. Find it on PubMed.

Mann, G., Hankey, G.J., & Cameron, D. (2000). Swallowing disorders following acute stroke: Prevalence and diagnostic accuracy. Cerebrovascular Diseases, 10, 380-386. Find it on PubMed.
Mann, G. (2002). MASA: The mann assessment of swallowing ability. Clifton Park, NY: Thomson Learning.

Ohira, M., Ishida, R., Maki, Y., Ohkubo, M., Sugiyama, T., Sakayori, T., & Sato, T. (2017). Evaluation of a dysphagia screening system based on the Mann Assessment of Swallowing Ability for use in dependent older adults. Geriatrics & gerontology international, 17(4), 561-567. Retrieved from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/ggi.12755

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