Toronto Bedside Swallowing Screening Test (TOR-BSST©)

Evidence Reviewed as of before: 18-02-2019
Author(s): Annabel McDermott, OT
Expert Reviewer: Trixie Reichardt, MHSc, RD, Rosemary Martino, PhD
Content consistency: Gabriel Plumier

Purpose

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a screening tool which identifies patients at risk for dysphagia following stroke.

In-Depth Review

Purpose of the measure

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a screening tool administered at the bedside by trained screeners which identifies patients at risk for dysphagia following stroke.

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 dysphagia 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 stroke, patients should undergo screening for swallowing difficulties before oral intake of food, fluids or oral medication. Screening should be performed by specially trained personnel, using a validated screening tool. Swallowing should be screened as soon as possible after admission provided that the patient is able to participate. Patients who fail the swallowing screening should be referred to a Speech-Language Pathologist for comprehensive swallowing assessment. For patients who are confirmed at high risk of aspiration and/or dysphagia 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 Dysphagia 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 stroke 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 stroke, patients should be assessed and managed according to best practice guidelines for dysphagia. 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 dysphagia 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 dysphagia following stroke.
What types of clients can the tool be used for? The TOR-BSST© was developed for patients with stroke across the recovery continuum.
Is this a screening or assessment tool? Screening 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
Reliability

Internal consistency:

  • No studies have reported on the internal consistency of the TOR-BSST©.

Test-retest:

  • No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:

  • No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:

  • Two studies have reported excellent inter-rater reliability of the TOR-BSST©. (Martino et al., 2006; Martino et al., 2009)
Validity

Content:

  • Development of the TOR-BSST© involved item generation from systematic review and subsequent item reduction, in combination with consultation with expert Speech-Language Pathologists. (Martino et al., 2000; Martino et al., 2009)

Criterion:

Concurrent:

  • No studies have reported on the concurrent validity 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/discriminant validity of the TOR-BSST©.

Known Groups:

  • No studies have reported on the known group validity of the TOR-BSST©.
Floor/Ceiling Effects Not applicable
Does the tool detect change in patients? The TOR-BSST© is designed as a screening 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 screening 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 screening test to determine risk of dysphagia. The screening should be discontinued as soon as an individual fails an item.

Reliability

Internal consistency:
No studies have reported on internal consistency of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:
Martino et al. (2009) established inter-rater reliability of the TOR-BSST© in the first 50 patients with stroke enrolled, using intraclass correlation coefficient (ICC) and 95% confidence intervals (CI). Results indicated excellent test-retest reliability (ICC=0.92; CI, 0.85 to 0.96).

Martino et al. (2006) examined 24-hour inter-rater reliability of the TOR-BSST© item and total screen scores in a sample of 286 patients with stroke (acute, n=78; subacute/chronic, n=208), using kappa statistics. Results indicated moderate reliability for the total score, with a higher reliability early after training (k = 0.90). Item reliability ranged from poor to adequate; the item ‘water swallowing’ including both the 50-ml and sip achieved the highest item reliability (k=0.82; CI, 0.66-0.98).

Validity

Content:

Initial item generation for the TOR-BSST© resulted from systematic review of the accuracy and benefit of non-invasive bedside dysphagia screening tests with patients with stroke (see Martino, Pron & Diamant, 2000). Two measures were shown to be accurate predictors of dysphagia 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 dysphagia. 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 stroke 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 dysphagia, 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 validity of the TOR-BSST©.

Predictive:
Martino et al. (2009) examined predictive validity of the TOR-BSST© by comparison with gold standard 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 stroke in acute and rehabilitation settings. Nine participants with stroke 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© screening; clinicians rated the VFS images using three standardized scales: (1) Penetration Aspiration Scale; (2) Mann Assessment of Swallowing Ability (MASA) dysphagia 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 dysphagia vs. 39% (n=23) with dysphagia. These results indicate high accuracy to predict dysphagia using the TOR-BSST©, where dysphagia is defined by aspiration and/or physiological abnormality on VFS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the TOR-SST©.

Known Group:
No studies have reported on the known-group validity of the TOR-BSST(c).

Sensitivity & Specificity

Martino et al. (2009) examined sensitivity of the TOR-BSST© by comparison with VFS assessment, in a sample of 68 patients with stroke 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% sensitivity (CI, 71.9 – 98.7) and 66.7% specificity (CI, 49.0 – 81.4) among all patients. Sensitivity and specificity 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 stroke settings, respectively.

Martino et al. (2014) conducted sensitivity analysis of the TOR-BSST© in the original sample of 311 patients with stroke from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses using the standard 10 teaspoons plus a sip of water. Positive screening 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 sensitivity of the TOR-BSST© when modifying administration according to water volume intake. Using the original sample from Martino et al. (2009), sensitivity was examined on administration of 1 to 10 teaspoons of water to determine the acceptable cut-point to identify dysphagia. Among all participants (n=311), sensitivity 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 standard)
  • Fiberoptic endoscopic examination of swallowing
  • Rosenbeck’s Penetration Aspiration Scale

Clinical Bedside Assessments:

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

Screening Tools:

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