Toronto Bedside Swallowing Screening Test (TOR-BSST©)

Purpose

The Toronto Bedside Swallowing ScreeningTesting for disease in people without symptoms.
Test (TOR-BSST©) is a screeningTesting for disease in people without symptoms.
tool which identifies patients at risk for dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

In-Depth Review

Purpose of the measure

The Toronto Bedside Swallowing ScreeningTesting for disease in people without symptoms.
Test (TOR-BSST©) is a screeningTesting for disease in people without symptoms.
tool administered at the bedside by trained screeners which identifies patients at risk for dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Available versions

There is one version of the TOR-BSST©. See https://swallowinglab.com/tor-bsst/.

Features of the measure

Items:

The TOR-BSST© is comprised of 5 items:

1. Baseline vocal quality
2. Tongue movement
3. 50mL water test
4. Cup sip
5. Final judgment of vocal quality

Scoring:

The TOR-BSST© uses binary scoring (i.e. abnormal/normal) for each item. Failure on any item discontinues the screen and prompts referral to a Speech-Language Pathologist dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
expert.

What to consider before beginning:

The TOR-BSST© should only be used with patients who are alert, able to sit upright at 90 degrees, and are able to follow simple instructions. Patients who do not meet these guidelines should not be screened but, instead, be referred to a Speech-Language Pathologist for assessment.

International best practice guidelines advise that, following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., patients should undergo screeningTesting for disease in people without symptoms.
for swallowing difficulties before oral intake of food, fluids or oral medication. ScreeningTesting for disease in people without symptoms.
should be performed by specially trained personnel, using a validated screeningTesting for disease in people without symptoms.
tool. Swallowing should be screened as soon as possible after admission provided that the patient is able to participate. Patients who fail the swallowing screeningTesting for disease in people without symptoms.
should be referred to a Speech-Language Pathologist for comprehensive swallowing assessment. For patients who are confirmed at high risk of aspiration and/or dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
should undergo an instrumental assessment such as videofluoroscopy swallowing study (VFS) and/or fibreoptic evaluation of swallowing (FEES).

Time:

The TOR-BSST© takes less than 10 minutes to administer and score. Administration ceases immediately on failure of an item.

Training requirements:

The TOR-BSST© can be administered by health professionals who have undergone the requisite 4-hour didactic standardized training program. Didactic training is followed by individual training/competency observations. Training is provided by Speech-Language Pathologists who have completed the “TOR-BSST© Training for the SLP DysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Expert” trainers course.

See The Swallowing Lab (https://swallowinglab.com/tor-bsst/) for details.

Equipment:

The TOR-BSST© is a one-page double-sided form that includes standardized instructions for administration

Client suitability

Can be used with:

• The TOR-BSST© is suitable for use with individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. across the recovery continuum (Martino et al., 2009).
• The TOR-BSST© is being validated for use with critically ill patients who have undergone prolonged intubation and may be at risk of swallowing problems.

Should not be used in:

• Following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., patients should be assessed and managed according to best practice guidelines for dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
  . The TOR-BSST© should not be used with individuals with decreased alertness or cognition, or those who are being tube-fed. Patients who are being tube-fed have already been identified to have dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
  and therefore should be referred to a Speech-Language Pathologist for a comprehensive assessment and management.

In what languages is the screening tool available?

• English
• French
• Chinese
• German
• Italian
• Portuguese (Brazil)

Summary

What does the tool measure?	Risk for dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration. following strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
What types of clients can the tool be used for?	The TOR-BSST© was developed for patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. across the recovery continuum.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. tool
Time to administer	Ten minutes.
Versions	There is one version of the TOR-BSST©.
Languages	Chinese, English, French, German, Italian, Portuguese (Brazil)
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have reported on the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the TOR-BSST©. Test-retest: No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the TOR-BSST©. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the TOR-BSST©. Inter-rater: Two studies have reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the TOR-BSST©.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: Development of the TOR-BSST© involved item generation from systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided. and subsequent item reduction, in combination with consultation with expert Speech-Language Pathologists. Criterion: Concurrent: No studies have reported on the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the TOR-BSST©. Predictive: One study has conducted a randomized controlled diagnostic study of the TOR-BSST© by comparison with videofluoroscopy. Construct: Convergent/Discriminant: No studies have reported on the convergent or discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess. of the TOR-BSST©. Known Groups: No studies have reported on the known group validityThe degree to which an assessment measures what it is supposed to measure. of the TOR-BSST©.
Floor/Ceiling Effects	Not applicable
Does the tool detect change in patients?	The TOR-BSST© is designed as a screeningTesting for disease in people without symptoms. test and scored using binary responses, so is not intended to detect change.
Acceptability	– The TOR-BSST© is quick to administer. – The TOR-BSST© requires specialised training.
Feasibility	The TOR-BSST© is suitable for administration across acute and rehabilitation settings. The screeningTesting for disease in people without symptoms. is easily portable and is quick to administer, score and interpret.
How to obtain the tool?	Click here for information regarding the TOR-BSST©.

Psychometric Properties

Overview

The TOR-BSST© was developed and validated by Dr. Martino of The Swallowing Lab, University Health Network, University of Toronto.

A literature search was conducted to identify all relevant publications on the psychometric properties of the TOR-BSST©. Four studies were identified.

Floor/Ceiling Effects

The TOR-BSST© is a 5-item screeningTesting for disease in people without symptoms.
test to determine risk of dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
. The screeningTesting for disease in people without symptoms.
should be discontinued as soon as an individual fails an item.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have reported on internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the TOR-BSST©.

Inter-rater:
Martino et al. (2009) established inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the TOR-BSST© in the first 50 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. enrolled, using intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. and 95% confidence intervals (CI). Results indicated excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC=0.92; CI, 0.85 to 0.96).

Martino et al. (2006) examined 24-hour inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the TOR-BSST© item and total screen scores in a sample of 286 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (acute, n=78; subacute/chronic, n=208), using kappa statistics. Results indicated moderate reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
for the total score, with a higher reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
early after training (k = 0.90). Item reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
ranged from poor to adequate; the item ‘water swallowing’ including both the 50-ml and sip achieved the highest item reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(k=0.82; CI, 0.66-0.98).

Validity

Content:

Initial item generation for the TOR-BSST© resulted from systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
of the accuracy and benefit of non-invasive bedside dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
screeningTesting for disease in people without symptoms.
tests with patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (see Martino, Pron & Diamant, 2000). Two measures were shown to be accurate predictors of dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
by videofluroscopic assessment (VFS) of aspiration, and a further two were considered to show promising (although inconsistent) predictive ability:

1. Dysphonia/coughing during the 50mL Kidd water swallow test
2. Impaired pharyngeal sensation
3. Impaired tongue movement
4. General dysphonia – voice before or voice after water intake

The final measure, general dysphonia, was defined as two sub-items (voice before, voice after).

Item reduction was then performed, whereby positive results across the 5 items were compared with the total score. The item ‘water swallow’ contributed 25% to the total positive score, indicating that this item was the most frequent single item to identify dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
. The item ‘tongue movements’ contributed 8% to the total positive score. The remaining items contributed less than 5% each to the total positive score, and so were considered for elimination on review of practical application as determined by expert Speech-Language Pathologists. These expert clinicians considered the item ‘pharyngeal sensation’ to be impractical due to difficulty differentiating from a gag reflex in the clinical setting.

Martino et al. (2014) conducted item descriptive analysis in the original sample of 311 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses. Items were eliminated individually to evaluate the impact of each item on the total score. Results showed that the ‘water swallow’ item contributed most significantly to identification of dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
, identifying 42.7% of patients in the acute setting and 29.0% of patients in the rehabilitation setting.

Criterion:

Concurrent:
No studies have reported on the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the TOR-BSST©.

Predictive:
Martino et al. (2009) examined predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the TOR-BSST© by comparison with gold standardA measurement that is widely accepted as being the best available to measure a construct.
VFS assessment identifying any abnormal swallow physiology including all severity. The randomized controlled diagnostic study design included four blinded Speech-Language Pathologists and 68 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in acute and rehabilitation settings. Nine participants with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart as per a priori criteria for patient flow. VFS assessment was used to confirm findings obtained by TOR-BSST© screeningTesting for disease in people without symptoms.
; clinicians rated the VFS images using three standardized scales: (1) Penetration Aspiration Scale; (2) Mann Assessment of Swallowing Ability (MASA) dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
subscore; and (3) MASA aspiration subscore. Across the entire sample of acute and rehab patients, results showed that 61% (n=36) of patients were confirmed by experts to have no dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
vs. 39% (n=23) with dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
. These results indicate high accuracy to predict dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
using the TOR-BSST©, where dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
is defined by aspiration and/or physiological abnormality on VFS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validityThe degree to which an assessment measures what it is supposed to measure.
of the TOR-SST©.

Known Group:
No studies have reported on the known-group validityThe degree to which an assessment measures what it is supposed to measure.
of the TOR-BSST(c).

Sensitivity & Specificity:

Martino et al. (2009) examined sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the TOR-BSST© by comparison with VFS assessment, in a sample of 68 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. in acute and rehabilitation settings. Nine patients were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart. The TOR-BSST showed 91.3% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
(CI, 71.9 – 98.7) and 66.7% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
(CI, 49.0 – 81.4) among all patients. SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
was 96.3% and 63.6% (respectively) among patients in an acute setting, and 80.0% and 68.0% (respectively) among patients in rehabilitation settings. The TOR-BSST© showed high negative predictive value of 93.3% and 89.5% in participants in acute and rehabilitation strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. settings, respectively.

Martino et al. (2014) conducted sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
analysis of the TOR-BSST© in the original sample of 311 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses using the standard 10 teaspoons plus a sip of water. Positive screeningTesting for disease in people without symptoms.
occurred in 59.2% of patients in the acute setting (n=103) and 38.5% of patients in the rehabilitation setting (n=208).

Martino et al. (2014) further examined sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the TOR-BSST© when modifying administration according to water volume intake. Using the original sample from Martino et al. (2009), sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
was examined on administration of 1 to 10 teaspoons of water to determine the acceptable cut-point to identify dysphagiaDifficulty, discomfort or pain in swallowing due to problems in nerve or muscle control. It is common in patients who have had a stroke. Dysphagia ranges from slight discomfort to complete inability to swallow. Dysphagia may compromise nutrition and hydration and may lead to aspiration pneumonia and dehydration.
. Among all participants (n=311), sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
ranged from moderate to excellent for 5, 8 and 10 teaspoons of water (79%, 92%, 96% respectively). Among patients in the acute setting and rehabilitation settings, sensitivities were 84% and 75% (respectively) for 5 teaspoons of water, 93% and 92% (respectively) for 8 teaspoons, and 95% and 97% (respectively) for 10 teaspoons. Results indicate greater accuracy on administration of 10x 5mL teaspoons of water, as per the original assessment guidelines

References

• Martino, R., Maki, E., & Diamant, N. (2014). Identification of dysphagia using the Toronto Bedside Swallowing Screening Test (TOR-BSST©): are 10 teaspoons of water necessary? International Journal of Speech-Language Pathology, 16(3), 193-8. https://www.ncbi.nlm.nih.gov/pubmed/24833425
• Martino, R., Nicholson, G., Bayley, M., Teasell, R., Silver, F., & Diamant, N. (2006). Interrater reliability of the Toronto Bedside Swallowing Screening Test (TOR-BSST©) [Abstract]. Dysphagia, 21(4), 287-334. https://doi.org/10.1007/s00455-006-9044-5
• Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15, 19-30. https://www.ncbi.nlm.nih.gov/pubmed/10594255
• Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D.L., & Diamant, N.E. (2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40, 555-61. https://www.ncbi.nlm.nih.gov/pubmed/19074483

See the measure

How to obtain the TOR-BSST©:

Click here for information regarding the TOR-BSST©.

Other measures of dysphagia:

Instrumental Assessments:

• Videofluoroscopy swallowing study (gold standardA measurement that is widely accepted as being the best available to measure a construct.
  )
• Fiberoptic endoscopic examination of swallowing
• Rosenbeck’s Penetration Aspiration Scale

Clinical Bedside Assessments:

• The Modified Mann Assessment of Swallowing Ability (Modified MASA)

ScreeningTesting for disease in people without symptoms.
Tools:

• Massey Bedside Swallowing Screen Volume-Viscosity Swallowing Test (Clave et al., 2008)
• The Gugging Swallowing Screen (GUSS) (Trapl et al., 2007)