ArticlePDF AvailableLiterature Review

Screening for aspiration risk associated with dysphagia in acute stroke

October 2021
Cochrane Database of Systematic Reviews 10(10)

DOI:10.1002/14651858.CD012679.pub2

Authors:

Elizabeth Boaden

University of Central Lancashire

Lucy Hives

University of Central Lancashire

Paola Dey

Edge Hill University

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Background: Stroke can affect people's ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties. Objectives: Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia - Patient demographics (e.g. age, gender) - Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified - Definition of dysphagia used by the study - Level of training of nursing staff (both grade and training in the screening tool) - Low-quality studies identified from the methodological quality checklist - Type and threshold of index test - Type of reference test SEARCH METHODS: In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy. Selection criteria: We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital. Data collection and analysis: Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests. Main results: Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)). We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests. Authors' conclusions: We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

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Screening for aspiration risk associated with dysphagia in acute

stroke (Review)



Boaden E, Burnell J, Hives L, Dey P, Clegg A, Lyons MW, Lightbody CE, Hurley MA, Roddam H,

McInnes E, Alexandrov A, Watkins CL



BoadenE, BurnellJ, HivesL, DeyP, CleggA, LyonsMW, LightbodyCE, HurleyMA, RoddamH, McInnesE, AlexandrovA,

WatkinsCL.

Screening for aspiration risk associated with dysphagia in acute stroke.

Cochrane Database of Systematic Reviews 2021, Issue 10. Art. No.: CD012679.

DOI: 10.1002/14651858.CD012679.pub2.

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www.cochranelibrary.com 

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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T A B L E  O F  C O N T E N T S

HEADER......................................................................................................................................................................................................... 1

ABSTRACT..................................................................................................................................................................................................... 1

PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2

SUMMARY OF FINDINGS.............................................................................................................................................................................. 4

BACKGROUND.............................................................................................................................................................................................. 8

OBJECTIVES.................................................................................................................................................................................................. 9

METHODS..................................................................................................................................................................................................... 9

Figure 1.................................................................................................................................................................................................. 11

RESULTS........................................................................................................................................................................................................ 13

Figure 2.................................................................................................................................................................................................. 15

Figure 3.................................................................................................................................................................................................. 17

Figure 4.................................................................................................................................................................................................. 18

Figure 5.................................................................................................................................................................................................. 19

Figure 6.................................................................................................................................................................................................. 20

Figure 7.................................................................................................................................................................................................. 21

Figure 8.................................................................................................................................................................................................. 22

Figure 9.................................................................................................................................................................................................. 23

Figure 10................................................................................................................................................................................................ 24

DISCUSSION.................................................................................................................................................................................................. 24

AUTHORS' CONCLUSIONS........................................................................................................................................................................... 27

ACKNOWLEDGEMENTS................................................................................................................................................................................ 27

REFERENCES................................................................................................................................................................................................ 28

CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 35

DATA.............................................................................................................................................................................................................. 78

Test 1. Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004)................................................................................ 81

Test 2. Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001)................................................................................ 81

Test 3. Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007)................................................................................................ 81

Test 4. Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009)........................................................................... 81

Test 5. Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2...................................................................... 81

Test 6. Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016).............................................................................................. 81

Test 7. Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009)........................................................................... 82

Test 8. Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010).......................................................................... 82

Test 9. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Edmiaston (2014)............................................. 82

Test 10. Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swallow test - Huhn-Matesic (2015)...................... 82

Test 11. Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001).............................................................................. 82

Test 12. Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia - Edmiaston (2014)........................................... 82

Test 13. Modified MASA (MMASA) Neurologist 1 - Antonios (2010).................................................................................................... 83

Test 14. Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016).......................................................................... 83

Test 15. Clinical examination - Daniels (1997).................................................................................................................................... 83

Test 16. Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010).......................................................................... 83

Test 17. Nurse Dysphagia Screen - Cummings (2015)........................................................................................................................ 83

Test 18. Modified MASA (MMASA) Neurologist 2 - Antonios (2010).................................................................................................... 83

Test 19. Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000).............................................................................................. 84

Test 20. Bedside swallow test - WST only - Lim (2001)....................................................................................................................... 84

Test 21. Chinese version of the modified SSA original 8 items - Jiang (2019)................................................................................... 84

Test 22. Chinese version of the modified SSA reduced 6 items - Jiang (2019).................................................................................. 84

Test 23. Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) - Bravata (2009)................................................ 84

Test 24. Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013).................................................................................................... 84

Test 25. 2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008).................................................................... 85

Test 26. Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels (2016)........................................................ 85

Test 27. Gag function - Test3 - Perry (2001)........................................................................................................................................ 85

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Test 28. DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera (2018).................................................................. 85

Test 29. DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018)......................................................................... 85

Test 30. Gag function - Test4 - Perry (2001)........................................................................................................................................ 85

Test 31. 2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008)....................................................................... 86

Test 32. Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen - Mulheren (2019)........................................... 86

Test 33. Nursing Screening Tool - Bravata (2009)............................................................................................................................... 86

Test 34. Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish version (T-BJH) - Eren (2019).............................. 86

Test 35. Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011).............................................................................................. 86

Test 36. TOR-BSST water swallow item - Martino (2014).................................................................................................................... 86

Test 37. Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005)............................................................................. 87

Test 38. Index taxonomy - water only................................................................................................................................................. 87

Test 39. Index taxonomy - water plus other consistencies................................................................................................................. 87

Test 40. Index taxonomy - other.......................................................................................................................................................... 87

Test 41. Outcome - aspiration.............................................................................................................................................................. 88

Test 42. Outcome - dysphagia.............................................................................................................................................................. 88

Test 43. Reference test - Expert Assessment and MASA..................................................................................................................... 89

Test 44. Reference test - FEES.............................................................................................................................................................. 89

Test 45. Reference test - VF.................................................................................................................................................................. 89

Test 46. HCP - nurse.............................................................................................................................................................................. 90

Test 47. HCP - other.............................................................................................................................................................................. 90

ADDITIONAL TABLES.................................................................................................................................................................................... 90

APPENDICES................................................................................................................................................................................................. 93

WHAT'S NEW................................................................................................................................................................................................. 101

HISTORY........................................................................................................................................................................................................ 101

CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 102

DECLARATIONS OF INTEREST..................................................................................................................................................................... 102

SOURCES OF SUPPORT............................................................................................................................................................................... 102

DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 102

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[Diagnostic Test Accuracy Review]

Screening for aspiration risk associated with dysphagia in acute stroke

Elizabeth Boaden1, Jane Burnell2, Lucy Hives2, Paola Dey3, Andrew Clegg2, Mary W Lyons4, C Elizabeth Lightbody5, Margaret A Hurley2,

Hazel Roddam6, Elizabeth McInnes7, Anne Alexandrov8, Caroline L Watkins5

1Faculty of Health and Care , University of Central Lancashire , Preston, UK. 2Faculty of Health and Care, University of Central Lancashire ,

Preston, UK. 3Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK. 4Liverpool School of Tropical Medicine, Liverpool, UK.

5Faculty of Health and Care, University of Central Lancashire, Preston, UK. 6Faculty of Allied Health and Well-being, University of Central

Lancashire, Preston, UK. 7Nursing Research Institute, Australian Catholic University, Sydney, Australia. 8University of Tennessee Health

Science Center (UTHSC), Memphis, Tennessee, USA

Contact address: Elizabeth Boaden, eboaden1@uclan.ac.uk.

Editorial group: Cochrane Stroke Group.

Publication status and date: New, published in Issue 10, 2021.

Citation: BoadenE, BurnellJ, HivesL, DeyP, CleggA, LyonsMW, LightbodyCE, HurleyMA, RoddamH, McInnesE, AlexandrovA,

WatkinsCL. Screening for aspiration risk associated with dysphagia in acute stroke. Cochrane Database of Systematic Reviews 2021, Issue

10. Art. No.: CD012679. DOI: 10.1002/14651858.CD012679.pub2.

A B S T R A C T

Background

Stroke can aect people’s ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest

infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased

likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces

risk of these diiculties.

Objectives

Primary objective

• To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration

associated with dysphagia in people with acute stroke

Secondary objectives

• To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia

- Patient demographics (e.g. age, gender)

- Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening

tools are identified

- Definition of dysphagia used by the study

- Level of training of nursing sta (both grade and training in the screening tool)

- Low-quality studies identified from the methodological quality checklist

- Type and threshold of index test

- Type of reference test

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Search methods

In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA)

database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted

experts in the field to identify any ongoing studies and those potentially missed by the search strategy.

Selection criteria

We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other

healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults

with acute stroke admitted to hospital.

Data collection and analysis

Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity

and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements.

The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool.

We identified insuicient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as

sensitivities and specificities for the index tests.

Main results

Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included

studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other

consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and

from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and

from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to

86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference,

six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fieen screening tools had an outcome

of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one

screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)).

We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across

all three applicability domains.

No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water

swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the

Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening

Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However,

clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes,

which limits the estimates of reliability of screening tests.

Authors' conclusions

We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least

one trial with low risk of bias. However, we were able to oer recommendations for further high-quality studies that are needed to improve

the accuracy and clinical utility of bedside screening tools.

P L A I N  L A N G U A G E  S U M M A R Y

Screening for aspiration risk associated with dysphagia in acute stroke

Question

How accurate are swallow screening tools for detecting when food and drink enter the airway in people with acute stroke?

Background

Stroke oen aects a person’s ability to swallow, allowing food and drink into the airway. This can cause choking, chest infection,

malnutrition, dehydration, and reduced rehabilitation, with increased risk of anxiety, depression, discharge to a care home, and death.

Early identification and management of disordered swallowing through the most accurate testing reduces these risks. If the test fails

to identify swallowing diiculties, the person will continue oral intake and may experience the diiculties identified above. If the test

incorrectly identifies swallowing diiculties, the person may not be given anything to eat or drink, significantly impacting quality of life,

until a more detailed assessment is undertaken (usually the next day).

Study characteristics

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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We identified 25 studies that used a total of 37 tools. Seven tools did not use water or other consistencies, 24 used only water, and six

considered water and other consistencies.

Key results

We were unable to identify a tool that could accurately identify everyone with food and drink entering their airway, as well as detect

all those who definitely did not. Many studies involved dierent healthcare professionals, food and fluid testing consistencies, and time

between stroke onset and the screening test, so it is unclear which tool is best. We were unable to directly compare the dierent tools

because most studies used dierent methods.

We were able to identify the tools most able to detect people with and without risk of swallowing diiculties from studies with good quality

evidence. The best combined water swallow and instrumental test was the Bedside Aspiration test, the best water plus other consistencies

tool was the Gugging Swallowing Screen, and the best water only tool was the Toronto Bedside Swallowing Screening Test. However,

clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes.

Quality of the evidence

Most included studies were poorly conducted or were unclear in reporting what they did (i.e. unclear or high risk of bias).

Conclusion

We were unable to identify a single tool with combined high levels of accuracy and good quality evidence. However, we are able to oer

recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of swallow screening tools.

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S U M M A R Y  O F  F I N D I N G S



Summary of findings 1.  Review criteria and findings

Review question What is the diagnostic accuracy of screening tools for aspiration risk associated with dysphagia in

acute stroke?

Importance A simple and reliable screening tool for identification of aspiration associated with dysphagia

would reduce diagnostic delay and the risk of developing pneumonia in acute stroke patients

Patients/population Patients (over the age of 18) who have been admitted to an acute hospital setting, where there is

a clinical diagnosis of stroke. Patients with subarachnoid haemorrhage were excluded from the

study

Settings Stroke units or hospital wards where acute stroke patients are admitted

Index tests Bedside swallowing screening tools carried out by healthcare professionals (excluding SLTs)

Reference standards Expert assessment, including the MASA

FEES

Studies 25 studies were included, 4 of which are presented as narratives (with no accuracy statistics report-

ed). The included studies reported 37 screening tests

Overall judgement: poor quality for the majority of studies – only 6 studies were at low risk across

all 4 risk of bias domains, and 2 studies were at low risk of bias for 3 domains

Patient selection bias: high risk = 12 studies; unclear risk = 11 studies; low risk = 2 studies

Index test interpretation bias: high risk = 14 studies; unclear risk = 10 studies; low risk = 1 study

Reference standard interpretation bias: high risk = 16 studies; unclear risk = 8 studies; low risk = 1

study

Risk of bias

Flow and timing selection bias: high risk = 13 studies; unclear risk = 6 studies; low risk = 6 studies

Concerns regarding patient selection: high risk = 16 studies; unclear risk = 4 studies; low risk = 5

studies

Concerns regarding index test: high risk = 20 studies; unclear risk = 4 studies; low risk = 1 study

Applicability concern

Concerns regarding reference standard: high risk = 22 studies; unclear risk = 3 studies; low risk = 0

studies

The best performing swallow screening tools were the Combined WST and Oxygen Saturation

Test (Lim 2001a), GUSS (Trapl 2007b), and TOR-BSST (Martino 2009). The best water only swallow

screening test was the TOR-BSST (Martino 2009). All demonstrate a combined highest sensitivity

and specificity and low risk of bias across all domains. These tools may be considered useful in clin-

ical practice

The water plus various consistencies (n = 6) performed better than the water-only tools in terms of

sensitivity and specificity

Overall findings

Only a few studies (e.g. GUSS) (Trapl 2007b) gave direction on what food and drink consistencies

should be given to an individual following the screen

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The quality of evidence varied. Studies often failed to distinguish between dysphagia and aspi-

ration as the primary outcome. Some did not identify the time interval between stroke onset or

admission to hospital and the screen, or the time interval between index test and reference test.

Training required by different healthcare professionals to implement the screening tool was not re-

ported well. This has implications for future research

FEES: fibreoptic endoscopic evaluation of swallowing.

MASA: Mann Assessment of Swallowing Ability.

SLT: speech and language therapist.

VF: videofluoroscopy.

WST: water-swallowing test.



Summary of findings 2.  Screening tests

Screening test N participants

(studies)

Reference stan-

dard

Diagnostic estimates

(95% CI)

Implications

Water-only tests 2914 (13)   

Toronto Bedside Swallowing

Screening Test (TOR-BSST): Mar-

tino 2009 Study 1

24 (1) VFSS Sens = 1.00 (0.75 to 1.00)

spec = 0.64 (0.31 to 0.89)

Insufficient evidence to al-

low firm conclusions

Acute Stroke Dysphagia Screen-

ing (ASDS) Aspiration: Edmias-

ton 2010

300 (1) Expert assess-

ment and MASA

Sens = 0.95 (0.87 to 0.99)

spec = 0.69 (0.62 to 0.75)

Large study with unclear

risk of bias and low applic-

ability concerns

Barnes-Jewish Hospital-Stroke

Dysphagia Screen (BJH-SDS) As-

piration: Edmiaston 2014

223 (1) VFSS Sens = 0.95 (0.86 to 0.99)

spec = 0.50 (0.42 to 0.58)

Large study with un-

clear/low risk of bias and

low applicability concerns

Edith-Huhn-Matesic Bedside As-

piration Screen (EHMBAS) fol-

lowed by simple water swallow

test: Huhn-Matesic 2015

52 (1) Expert assess-

ment and MASA

Sens = 0.94 (0.71 to 1.00)

spec = 0.77 (0.60 to 0.90)

Insufficient evidence to al-

low firm conclusions

Barnes-Jewish Hospital-Stroke

Dysphagia Screen (BJH-SDS)

Dysphagia: Edmiaston 2014

225 (1) VFSS Sens = 0.94 (0.88 to 0.98)

spec = 0.66 (0.57 to 0.75)

Large study with low risk

of bias and low applicabili-

ty concerns.

Rapid Aspiration Screening

for Suspected Stroke (RAS3):

Daniels 2016

250 (1) VFSS Sens = 0.93 (0.77 to 0.99)

spec = 0.43 (0.36 to 0.50)

Large study with low risk

of bias and low applicabili-

ty concerns.

Clinical examination: Daniels

1997

59 (1) VFSS Sens = 0.92 (0.75 to 0.99)

spec = 0.64 (0.45 to 0.80)

Insufficient evidence to al-

low firm conclusions

Acute Stroke Dysphagia Screen-

ing (ASDS) Dysphagia: Edmias-

ton 2010

300 (1) Expert assess-

ment and MASA

Sens = 0.91 (0.83 to 0.96)

spec = 0.75 (0.68 to 0.80)

Large study with unclear

risk of bias and low applic-

ability concerns

Nurse Dysphagia Screen: Cum-

mings 2015

49 (1) Expert assess-

ment and MASA

Sens = 0.89 (0.65 to 0.99)

spec = 0.90 (0.74 to 0.98)

Insufficient evidence to al-

low firm conclusions

Bedside swallow test - WST on-

ly: Lim 2001

50 (1) FEES Sens = 0.85 (0.65 to 0.96)

spec = 0.75 (0.53 to 0.90)

Insufficient evidence to al-

low firm conclusions

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Chinese version of the modi-

fied SSA – original 8 items: Jiang

2019

127 (1) Expert assess-

ment and MASA

Sens = 0.83 (0.71 to 0.91)

spec = 0.59 (0.46 to 0.71)

Insufficient evidence to al-

low firm conclusions

Chinese version of the modified

SSA – reduced 6 items: Jiang

2019

127 (1) Expert assess-

ment and MASA

Sens = 0.81 (0.69 to 0.90)

spec = 0.64 (0.51 to 0.76)

Insufficient evidence to al-

low firm conclusions

2-step swallowing provocation

test (SPT) - step 1 - 0.4 mL: War-

necke 2008

100 (1) FEES Sens = 0.74 (0.63 to 0.83)

spec = 1.00 (0.82 to 1.00)

Insufficient evidence to al-

low firm conclusions

Rapid Aspiration Screening for

Suspected Stroke (RAS3) - WST

only: Daniels 2016

250 (1) VFSS Sens = 0.72 (0.53 to 0.87)

spec = 0.60 (0.53 to 0.66)

Large study with low risk

of bias and low applicabili-

ty concerns.

Gag function - Test3: Perry 2001

Study 1

22 (1) Expert assess-

ment and MASA

Sens = 0.71 (0.42 to 0.92)

spec = 0.63 (0.24 to 0.91)

Insufficient evidence to al-

low firm conclusions

DePaul Hospital Swallow

Screener (DHSS) Aspiration: Be-

hera 2018

226 (1) Expert assess-

ment and MASA

Sens = 0.70 (0.55 to 0.83)

spec = 0.90 (0.85 to 0.94)

Large study with unclear

risk of bias and unclear ap-

plicability concerns

DePaul Hospital Swallow

Screener (DHSS) Dysphagia: Be-

hera 2018

225 (1) Expert assess-

ment and MASA

Sens = 0.68 (0.55 to 0.80)

spec = 0.93 (0.88 to 0.96)

Large study with unclear

risk of bias and unclear ap-

plicability concerns

Gag function - Test4: Perry 2001

Study 1

157 (1) Expert assess-

ment and MASA

Sens = 0.67 (0.57 to 0.76)

spec = 0.78 (0.65 to 0.88)

Insufficient evidence to al-

low firm conclusions

2-step swallowing provocation

test (SPT) - step 2 - 2.0 mL: War-

necke 2008

100 (1) FEES Sens = 0.49 (0.38 to 0.61)

spec = 1.00 (0.82 to 1.00)

Insufficient evidence to al-

low firm conclusions

Johns Hopkins Hospital Brain

Rescue Unit Modified 3 oz Swal-

low Screen: Mulheren 2019

48 (1) VFSS Sens = 0.46 (0.28 to 0.66)

spec = 1.00 (0.83 to 1.00)

Insufficient evidence to al-

low firm conclusions

Water plus consistencies tests 412 (5)   

Registered Dietitian (RD) Dys-

phagia Screening tool: Huh-

mann 2004

32 (1) Expert assess-

ment and MASA

Sens = 1.00 (0.69 to 1.00)

spec = 0.86 (0.65 to 0.97)

Insufficient evidence to al-

low firm conclusions

Gugging Swallowing Screen

(GUSS) - Group2: Trapl 2007

30 (1) FEES Sens = 1.00 (0.77 to 1.00)

spec = 0.69 (0.41 to 0.89)

Insufficient evidence to al-

low firm conclusions

Standardized Swallowing As-

sessment tool (SSA) – Test2: Per-

ry 2001 Study 1

68 (1) Expert assess-

ment and MASA

Sens = 0.97 (0.86 to 1.00)

spec = 0.90 (0.74 to 0.98)

Insufficient evidence to al-

low firm conclusions

Nursing Bedside Dysphagia

Screen (NBDS): Campbell 2016

75 (1) Expert assess-

ment and MASA

Sens = 0.97 (0.90 to 1.00)

spec = 0.75 (0.35 to 0.97)

Insufficient evidence to al-

low firm conclusions

Standardized Swallowing As-

sessment tool (SSA) - Test1: Per-

ry 2001 Study 1

161 (1) Expert assess-

ment and MASA

Sens = 0.94 (0.87 to 0.98)

spec = 0.75 (0.63 to 0.84)

Insufficient evidence to al-

low firm conclusions

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Nursing Bedside Swallowing

Screen (NBSS): Ellis 2013

46 (1) Expert assess-

ment and MASA

Sens = 0.75 (0.35 to 0.97)

spec = 0.89 (0.75 to 0.97)

Insufficient evidence to al-

low firm conclusions

Other tests 627 (5)   

Bedside aspiration - Combined

WST & Oxygen Saturation: Lim

2001

50 (1) FEES Sens = 1.00 (0.87 to 1.00)

spec = 0.71 (0.49 to 0.87)

Insufficient evidence to al-

low firm conclusions

Emergency Department (ED)

dysphagia screen: Turn-

er-Lawrence 2009

84 (1) Expert assess-

ment and MASA

Sens = 0.96 (0.86 to 0.99)

spec = 0.56 (0.38 to 0.72)

Insufficient evidence to al-

low firm conclusions

Modified MASA (MMASA) Neurol-

ogist 1: Antonios 2010

150 (1) Expert assess-

ment and MASA

Sens = 0.93 (0.82 to 0.98)

spec = 0.86 (0.78 to 0.93)

Insufficient evidence to al-

low firm conclusions

Modified MASA (MMASA) Neurol-

ogist 2: Antonios 2010

150 (1) Expert assess-

ment and MASA

Sens = 0.87 (0.75 to 0.95)

spec = 0.84 (0.76 to 0.91)

Insufficient evidence to al-

low firm conclusions

Oxygen saturation ≥ 2% - Test2

for Aspiration: Smith 2000

53 (1) VFSS Sens = 0.87 (0.60 to 0.98)

spec = 0.39 (0.24 to 0.57)

Insufficient evidence to al-

low firm conclusions

Stroke Severity using National

Institutes of Health Stroke Scale

(NIHSS): Bravata 2009

101 (1) Expert assess-

ment and MASA

Sens = 0.79 (0.63 to 0.90)

spec = 0.68 (0.55 to 0.79)

Insufficient evidence to al-

low firm conclusions

Nursing Screening Tool: Bravata

2009

39 (1) Expert assess-

ment and MASA

Sens = 0.29 (0.08 to 0.58)

spec = 0.84 (0.64 to 0.95)

Insufficient evidence to al-

low firm conclusions

FEES: fibreoptic endoscopic evaluation of swallowing.

MASA: Mann Assessment of Swallowing Ability.

sens: sensitivity.

spec: specificity.

VFSS: videofluoroscopic swallowing study.

WST: water-swallowing test.

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B A C K G R O U N D

Stroke is the second most common cause of death worldwide

(Katan 2018), and it is the largest cause of complex preventable

disability in adults (WHF 2016). Over 13.7 million new strokes

are reported globally each year (Johnson 2019), with a projected

increase in incidence due to an ageing population (Avan 2019).

The reported incidence of dysphagia (swallowing diiculties)

following acute stroke varies between 37% and 78% (Martino

2005); this is related to type and severity of stroke and individual

characteristics (e.g. comorbidities). It is also related to the type

of diagnostic assessment used to detect dysphagia and time from

admission to that assessment. Dysphagia may lead to aspiration,

defined as food or fluid entering the airway below the level of

the vocal cords (Blitzer 1988), then into the trachea. People with

dysphagia are three times, and those with aspiration 11 times, more

likely to develop pneumonia (Kumar 2010; Rofes 2011), which is a

significant cause of further morbidity leading to increased hospital

stay and risk of death (Intercollegiate Stroke Working Party 2012).

Stroke-associated pneumonia is more common if identification

of dysphagia is delayed because of aspiration of food, drink,

medications, and oral secretions (Bray 2016). Therefore, early

screening for dysphagia may be an important avenue for reducing

deaths from acute stroke (Bray 2016; Donovan 2013).

Internationally, dierent clinical guidelines are available for

detecting swallowing diiculties in acute stroke. Identification of

dysphagia is a criterion that is considered for obtaining Stroke Unit

accreditation by the European Stroke Organisation. Within the UK,

Europe, Canada, the USA, and Australia, guidelines state that on

admission to hospital, people with acute stroke should have their

swallowing screened promptly following admission (European

Stroke Organisation 2015; Intercollegiate Stroke Working Party

2016; National Stroke Foundation 2010; Powers 2019; Teasell 2019).

Diagnostic methods such as videofluoroscopy (VF) and fibreoptic

endoscopic evaluation of swallowing (FEES) are available.

However, these methods have significant limitations when used

for early identification of dysphagia in acute stages of stroke.

Limitations may be patient specific (patients may be unable to

comply with instructions due to poor posture, cognition, medical

state, or fluctuating swallowing ability); organisational (speech and

language therapists (SLTs) may not be available in the acute setting,

and in most hospitals, instrumental examinations such as VF and

FEES can be requested only aer SLT evaluation; furthermore, not

all sta are trained to interpret the results of these reference tests);

or procedural (specialist equipment is not available in all acute

settings) (Boaden 2011). Therefore, screening tools are needed to

identify those likely to have dysphagia, who might be at greater risk

of aspiration, so that interventions can be put in place to reduce

morbidity until access to specialist equipment and sta is available

for assessment and/or until the patient is fit enough to undergo

the procedures. These screening tools are called bedside swallow

screening tools.

Bedside swallow screening tools must be quick and easy to

administer. To be clinically useful, screening tools must accurately

identify those with dysphagia with its associated risk of aspiration

(sensitivity), without leading to unnecessary restrictions (e.g.

withholding food and drinks) for those who do not have dysphagia

(specificity). The outcome of a screening test is binary (present or

not), although it is acknowledged there may be dierent levels of

severity of swallowing diiculty and subsequent management. A

positive test should lead to a referral for more definitive assessment

to confirm the presence of dysphagia or not, when this is available.

Screening tools also need to be acceptable and feasible for use

in people with a range of sequelae following stroke (e.g. dierent

levels of consciousness, cognitive levels, postural diiculties).

Screening tools must be undertaken prior to any oral intake and

therefore need to be administered by sta members who are at the

bedside throughout a 24-hour period.

There is wide variation in available screening tools. Some swallow

screening tools rely on questionnaires, whilst others use food and

drink as testing materials. Swallow screening tools vary in the

types of foods and fluids tested. Water swallow tools, such as the

Standardised Swallow Assessment (Perry 2001 Study 1), or the

Massey Bedside Swallow Screen (Massey 2002), are very similar in

that they oer people dierent quantities of fluids from assorted

utensils; some studies use water plus a range of consistencies

to prescribe food and drink consistency management plans. This

group of swallow screening tests are more dissimilar from each

other as they oer a variety of food and drink, give dierent

consistencies, trial dierent volumes, and alter the order in which

foods and drinks are oered. One concern is that some of these

tools have been developed and assessed with various reference

tests and dierent professional groups not routinely available at

the bedside, which limits their clinical utility.

There is no universally accepted screening tool for identification

and management of aspiration associated with dysphagia, and

a wide range of screening tests are used in clinical practice

throughout the world. A false-negative result is much worse than

a false-positive result. If the swallow screening test fails to identify

swallowing diiculties, the person will continue oral intake and

may experience the diiculties identified above. If the swallow

screening test erroneously identifies swallowing diiculties, the

patient is placed 'nil by mouth', with significant impact on quality of

life, until the SLT undertakes a more detailed assessment (usually

the next day). So a bedside swallow screening tool should be

chosen while taking into account this simple clinical reality. Hence,

there is a need to identify the most clinically useful screening test

or tools that most accurately identify the presence or absence of

aspiration associated with dysphagia, and to prescribe a food and

drink consistency management plan for individuals with aspiration

to improve their medical, social, and psychological outcomes.

Target condition being diagnosed

Aspiration risk associated with dysphagia in people who have had

an acute stroke.

Index test(s)

In this review, bedside swallowing screening tests not administered

by SLTs are the index tests. A wide range of index tests (swallow

screening tests) are used at the bedside by healthcare professionals

for recognition or determination of whether the patient is at risk of

aspirating food and fluids.

Clinical pathway

Bedside swallow screening tests are commonly used in the typical

care pathway in compliance with clinical guidelines for stroke.

However, there are varying degrees of compliance. Usually these

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tests are implemented by allied healthcare professionals (mainly

nurses) following admission to the acute care sector. Patients who

are identified as at risk of swallowing diiculties are oen placed

'nil by mouth' while awaiting an expert assessment or a further

reference test. The care pathway for patients who have a negative

test result usually allows patients to continue to eat and drink

orally.

Prior test(s)

No tests to assess swallowing are conducted on patients before

hospital admission.

Role of index test(s)

Index tests, that is, bedside screening tests not administered by

SLTs, have the potential to improve the identification of people

with risk of aspiration associated with dysphagia following stroke.

Therefore, these tests may reduce the need for SLT evaluation and

for more complex, invasive, and more expensive imaging methods,

such as VF, FEES, or scintigraphy, which may not be available in

some healthcare settings.

Alternative test(s)

Other index tests include questionnaires that rely on self-

reported dysphagia symptoms. However, these tools, for example,

the Sydney Swallow Questionnaire (SSQ) and the Swallowing

Disturbance Questionnaire (SDQ), were used or designed and

validated for use in patient populations such as those with head

and neck cancer or Parkinson’s disease. These are not considered

in this review.

Rationale

We reviewed the diagnostic accuracy of currently available swallow

screening tests. A systematic review of published evaluations of

these screening tests will assist practitioners to identify those that

have undergone rigorous development and testing. This review will

also identify gaps in evidence for further research.

Healthcare professionals within acute stroke care settings are

responsible for deciding which bedside swallow screening test

they will use to detect people at risk of aspiration associated

with dysphagia in adult acute stroke patients. When a bedside

swallow screening test is considered, a test with high sensitivity and

specificity is paramount. False-negative results may lead to serious

consequences within the clinical context, as continued oral intake

may precipitate aspiration pneumonia and death. High specificity is

also beneficial, as false-positive results may result in patients being

designated ‘nil by mouth’ and provided with clinically assisted

nutrition and hydration unnecessarily. This adversely aects the

well-being of the patient and incurs unnecessary costs. However,

false-positive results are less dangerous, in that usually an SLT will

see the patient within 24 hours.

A recent systematic review of bedside swallow screening tests

provided a descriptive analysis of the dierent elements within

screening tests but did not compare these with a reference standard

(Almeida 2015). Other reviews have not specifically focused on

a stroke population (Brodsky 2016; O'Horo 2015), have included

studies in which screening was not undertaken in a timely manner

(Schepp 2012), have focused on individual clinical determinants

or behaviours associated with aspiration (Daniels 2012), have

reviewed only multi-consistency tests (Benfield 2020), or have

accepted delays longer than 24 hours between the index test and

the reference standard (Daniels 2012). The results of this review

will help guide policy makers and healthcare workers in acute

hospital settings on selection of the most appropriate bedside

swallow screening test from those currently available and might

also identify the research agenda going forward.

O B J E C T I V E S

Primary objective

•To determine the diagnostic accuracy and the sensitivity and

specificity of bedside screening tests for detecting risk of

aspiration associated with dysphagia in people with acute

stroke

Secondary objectives

•To assess the influence of the following sources of heterogeneity

on the diagnostic accuracy of bedside screening tools for

dysphagia

*Patient demographics (e.g. age, gender)

*Time post stroke that the study was conducted (from

admission to 48 hours) to ensure only hyperacute and acute

stroke swallow screening tools are identified

*Definition of dysphagia used by the study

*Level of training of nursing sta (both grade and training in

the screening tool)

*Low-quality studies identified from the methodological

quality checklist

*Type and threshold of index test

*Type of reference test

M E T H O D S

Criteria for considering studies for this review

Types of studies

We considered single-gate and two-gate studies if they compared

the accuracy of a bedside screening tool administered by

nursing sta or other healthcare professionals (excluding SLTs)

with identified reference tests (VF, FEES, scintigraphy, expert

assessment). We applied no restrictions in terms of language of

publication.

Participants

We included studies if they involved adults (aged 18 and over)

who had been admitted to an acute hospital setting with a clinical

diagnosis of stroke. We considered studies that were inclusive

of people with subarachnoid haemorrhage and we excluded

this sample subgroup from the analysis, when possible. We

excluded studies that included only patients with subarachnoid

haemorrhage. We also excluded studies that admitted patients with

trauma.

Index tests

We included studies if they evaluated a bedside swallow screening

test, used by nursing sta or other healthcare professionals

(excluding SLTs who have expert knowledge in this area), for

recognition or determination of whether patients were at risk of

aspiration associated with dysphagia.

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Target conditions

We included studies if they reported the accuracy of the bedside

screening tool for identification of the risk of aspiration owing to

dysphagia post stroke.

Reference standards

We included studies if a bedside swallow screening test, carried

out by nursing sta or other healthcare professionals, was

compared with VF, FEES, scintigraphy, or an expert assessment.

Videofluoroscopy is an X-ray video of swallowing, allowing the

swallow to be analysed in real time. FEES involves insertion

of a fibreoptic flexible endoscope that is passed through the

nasal passages to view the throat pre-swallows and post-

swallows for secretion management, residue, and aspirated

material. Scintigraphy uses radioisotopes that are swallowed,

and the emitted radiation is captured by external detectors

(gamma cameras) to form images of swallowed material. Expert

assessments included assessments conducted by dysphagia-

trained professionals such as SLTs. All reference standards are

not equally valid and available (the SLT is not usually available

in the acute setting and is not available 24 hours each day and

seven days a week), and some procedures are more invasive than

others. Expert assessment was included as a reference standard

owing to the lack of immediate access to imaging or instrumental

assessment in many centres, and to the inability of some patients to

co-operate with these assessments. However, expert assessments

have limitations in their ability to identify at bedside those patients

who have swallowing diiculties owing to silent aspiration when

the patient demonstrates no clinical signs of aspiration.

Search methods for identification of studies

Electronic searches

The search strategy used was developed with the help of

the Cochrane Stroke Group Information Specialist. We searched

relevant electronic databases for eligible diagnostic studies from

inception until 9 December 2019: the Cochrane Central Register

of Controlled Trials (CENTRAL; 2019, Issue 12), in the Cochrane

Library; MEDLINE Ovid (from 1946); Embase Ovid (from 1980); the

Cumulative Index to Nursing and Allied Health Literature (CINAHL)

EBSCO (from 1937 onward), and the Health Technology Assessment

(HTA) Database via the Centre for Reviews and Dissemination

(University of York). The search strategy for MEDLINE is presented

in Appendix 1 and was adapted for CENTRAL (Appendix 2), Embase

(Appendix 3), CINAHL (Appendix 4), and HTA (Appendix 5).

Searching other resources

We checked the reference lists of all included studies, and we

performed a cited reference search using Science Citation Index, to

identify additional relevant studies and systematic reviews. We also

contacted experts in the field to identify ongoing studies and those

potentially missed by the search strategy.

We searched targeted grey literature sources, which we identified

from the the Canadian Agency for Drugs and Technologies in Health

(CADTH) Grey Matters document (CADTH 2018). A full list of the grey

literature sources searched is displayed in Appendix 6.

Data collection and analysis

Selection of studies

Two review authors from the team (EB, JB, HR, DD) independently

screened all titles and abstracts identified by the electronic

database searches and excluded duplications and irrelevant

records. Conflicts were resolved by involvement of a third

review author (PD, AA). We then obtained full-text articles for

the remaining studies, which were independently assessed for

inclusion by two review authors (EB, ML, HR, PD) using the

eligibility criteria described above. Disagreements were resolved

by consensus meetings, with arbitration provided by a third review

author (AA) who had not initially reviewed the paper. When multiple

papers used the same cohort of patients, we used the paper

with the most complete and up-to-date data. When we identified

relevant conference abstracts, we looked for the corresponding full-

text article. If we found no full-text article, we contacted the authors

of the conference abstract. We excluded conference abstracts with

insuicient data to calculate the 2 × 2 table. The selection process

is detailed in the PRISMA flow diagram in Figure 1.

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Figure 1.  PRISMA flow diagram.

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Figure 1.  (Continued)



Data extraction and management

Two review authors (JB, EM) designed a bespoke data extraction

form to collect details from the included studies. We piloted the

form on other diagnostic accuracy studies related to acute stroke

management that are beyond the scope of this review. For each

study, we extracted information related to characteristics of the

study, the patient population, index tests, reference standards, and

any relevant outcomes.

Among a group of review authors (JB, AC, LH, CEL, ML, CW), two

independently extracted the data to ensure adequate reliability and

quality. These two review authors then met to agree on final data

extractions for each included study. When there was disagreement

between the two review authors, a third review author from the

group acted as an arbitrator. Once data extraction was complete,

we entered the information into RevMan 5 (Review Manager 2014).

Assessment of methodological quality

Two review authors from the group (JB, AC, LH, CEL, ML,

CW) independently reviewed the methodological quality of each

included study, using criteria from the Quality Assessment of

Studies of Diagnostic Accuracy (QUADAS-2) tool, as recommended

by Cochrane (Appendix 7). As with previous diagnostic test accuracy

reviews (Gupta 2016), we changed the QUADAS-2 question "Was a

case-control design avoided?" to "Was a two-gate design avoided?".

We piloted the QUADAS-2 to promote agreement in interpretation

within the team. We resolved disagreements with a third review

author. We rated the QUADAS-2 criteria as ’yes’, ’no’, or ’unclear’

for each included study. As stated in our protocol, guidance

indicates that criteria 1, 2, 3, and 9 should receive particular

attention regarding definitions used as the basis for decisions.

The other criteria are more self-explanatory with regards to their

interpretation.

Statistical analysis and data synthesis

From each index test, the parameters of interest were sensitivity

and specificity. For a majority of index tests, these were calculated

from the 2 × 2 tables. For other index tests, information from

reported parameters (sensitivity, specificity, or predictive values)

was used to inform the 2 × 2 table, yielding true-positive, false-

positive, true-negative, and false-negative values. From available

information, sensitivities, specificities, and their 95% confidence

intervals were calculated by RevMan 5 and plotted in forest plots

and summary receiver operating characteristic (SROC) plots. In

the absence of suicient data, to calculate the 2 × 2 tables, we

contacted study authors for further information. If this information

remained unavailable, we included the study in the review as a

narrative study.

Data from a single study were used only once in each analysis. We

checked all studies to see if all patients were included, or if the

number of patients was fixed, a priori in the design, from a condition

(from the reference test) or from the index test. If the numbers

of patients were fixed, the formulae for sensitivity and specificity

would be dierent. No included studies used such numbers fixed a

priori.

Pooling of sensitivity and specificity results was intended for each

index test. However, due to the small number of studies using the

same index test (three or fewer), we did not perform any meta-

analyses of diagnostic accuracy data. Pooling of screening tests

by general categories was performed as part of the descriptive

analysis, presented along with sensitivity and specificity.

Investigations of heterogeneity

Possible co-variates of interest were patient demographics (e.g.

age, gender), time post stroke that the study was conducted,

and level of training of nursing sta. However, the potential

influence of these co-variates could not be investigated due to

the small number of studies for each index test. The definitions

of dysphagia used by the study could have been grouped, and

the type and quality of the reference test, as well as the type

of index test, investigated as sources of heterogeneity. For the

same reason, no subgroup analyses were performed involving age,

gender, time post stroke of the index test, or index test type, and

whether there had been a significant change in the participant’s

condition between performance of index and reference tests. Index

tests were pooled by broad categories (by index test type, by

healthcare professional (HCP), by outcome, and by reference test),

and graphical comparisons were made. We therefore performed

only a narrative review running exploratory analysis in RevMan 5 to

show graphically if the co-variates of interest are likely to be related

to test accuracy, displayed using forest plots and SROC plots.

Sensitivity analyses

We did not carry out any sensitivity analyses due to the small

number of studies for each index test. We had proposed to exclude

low-quality studies and possibly reporting a delay in time between

index and reference tests due to potential changes in patient

consciousness and cognitive state.

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Assessment of reporting bias

Since no methods are available to quantify publication bias in

diagnostic test accuracy reviews, we did not conduct an assessment

of reporting bias.

R E S U L T S

Results of the search

We conducted two searches - the first in June 2017 and the

same search in December 2019. We identified 26,701 papers

through database searches, and we found two additional studies

by handsearching the references of existing systematic reviews,

for a total of 20,567 articles once duplicates were removed. Aer

titles and abstracts of articles had been screened, we assessed

the full texts of 233 articles against the eligibility criteria. Of these,

we excluded 208 articles - 35 because they did not compare

appropriate index and reference tests, 24 because they did not

involve consecutive acute stroke patients, 16 because they did not

relate to screening for dysphagia, eight because index tests were

carried out by experts, three because they involved only patients

with dysphagia or aspiration and so sensitivity and specificity

could not be calculated, two because they were not single-gate

or two-gate studies, and one because not all patients received

the same reference test (see Characteristics of excluded studies).

Additionally, we excluded 57 references that were conference

abstracts, 38 that were not primary research studies, 12 that were

duplicate papers, six that had been withdrawn or were unavailable,

three that were research protocols or trial registrations, two that

were Master's or PhD theses, and one that was not relevant. Twenty-

five articles went through to data extraction and were included

in the final review. Four of the included articles did not include

enough detail for calculating the diagnostic accuracy of the index

test, thus we included these in narrative descriptions only. More

detail is shown in the PRISMA diagram (Figure 1).

We checked the reference lists of included studies, but this did

not reveal additional eligible papers. Details on participants, index

tests, reference tests, and sensitivity and specificity of each index

test are displayed in the Characteristics of included studies table.

The 25 included studies investigated a total of 37 screening tools,

most of which were dierent tools. All 25 studies are single-gate

studies. Of 37 screening tools, 21 were used by nurses and 16

by other HCPs. The other HCPs were doctor or physician (n = 6),

dietician (n = 1), neurologist (n = 2), multiple HCPs (n = 4), and HCP

not recorded (n = 3). Of the 37 screening tools, four could not be

included in an available quantitative analysis as 2 × 2 tables could

not be constructed to estimate sensitivity or specificity (Eren 2019;

Martino 2014; Nishiwaki 2005; Zhou 2011). Training was given for

screening tools used by 17 (81%) nurses and by four (25%) other

HCPs.

Demographic information and characteristics of all 37 screening

tests (including the four narrative tests) are given in Table 1. When

reported, mean age was 58.6 years to 76.8 years, the percentage

of males in the study was 35% to 100%, and the start date of

study recruitment was between 1995 and 2016. Twenty-two (59%)

tests were conducted in the USA and Canada, eight (22%) in the

UK and Europe, and six (16%) in other countries; in one (3%)

study, the country was not recorded. Only two (5%) studies used

an established classification system to record the location of the

stroke. The median sample size was 100, with an interquartile range

(IQR) of 50 to 161; 16 (48%) screening tools had a sample size less

than 100.

For 16 (43%) tests, admission to index test time was ≤ 24 hours, for

six (16%) between 24 hours and 72 hours, and for two (5%) ≥ 72

hours; for 13 (35%), this information was not recorded. For 28 (76%)

tests the index test was applied before the reference test, for one

(3%) the reference test was applied before the index test, for five

(14%) the order was not specified or mixed, and for three (8%) this

was not recorded. The time interval between index and reference

tests was ≤ 24 hours for 18 (49%) tests, was > 24 hours for 10 (27%)

tests, and was not recorded for nine (24%) tests.

Twenty-four (64.9%) screening tools used water only (Behera

2018a; Behera 2018b; Cummings 2015; Daniels 1997; Daniels 2016a;

Daniels 2016b; Edmiaston 2010a; Edmiaston 2010b; Edmiaston

2014a; Edmiaston 2014b; Eren 2019; Huhn-Matesic 2015; Jiang

2019a; Jiang 2019b; Lim 2001b; Martino 2009 Study 1; Martino

2014; Mulheren 2019; Nishiwaki 2005; Perry 2001 Study 1a; Perry

2001 Study 1b; Warnecke 2008a; Warnecke 2008b; Zhou 2011), six

(16.2%) used water and other consistencies (Campbell 2016; Ellis

2013; Huhmann 2004; Perry 2001 Study 1c; Perry 2001 Study 1d;

Trapl 2007b), and seven (18.9%) used other methods. The other

methods were evaluation of patient characteristics only (Antonios

2010a; Antonios 2010b; Bravata 2009a), notes review (Bravata

2009b), combined water swallow test and oxygen saturation

(Lim 2001a), oxygen saturation (Smith 2000), and evaluation of

patient characteristics followed by water swallow test and oxygen

saturation (Turner-Lawrence 2009). Several references reported use

of more than one screening tool as detailed in Table 2.

Expert assessment or the Mann Assessment of Swallowing Ability

(MASA) was utilised for 20 (54.1%) screening tools as the reference

test (Antonios 2010a; Antonios 2010b; Behera 2018a; Behera 2018b;

Bravata 2009a; Bravata 2009b; Campbell 2016; Cummings 2015;

Edmiaston 2010a; Edmiaston 2010b; Ellis 2013; Huhmann 2004;

Huhn-Matesic 2015; Jiang 2019a; Jiang 2019b; Perry 2001 Study

1a; Perry 2001 Study 1b; Perry 2001 Study 1c; Perry 2001 Study

1d; Turner-Lawrence 2009); six (16.2%) used FEES (Eren 2019; Lim

2001a; Lim 2001b; Trapl 2007b; Warnecke 2008a; Warnecke 2008b),

and 11 (29.7%) used VF (Daniels 1997; Daniels 2016a; Daniels 2016b;

Edmiaston 2014a; Edmiaston 2014b; Martino 2009 Study 1; Martino

2014; Mulheren 2019; Nishiwaki 2005; Smith 2000; Zhou 2011).

We identified 15 (40.5%) screening tools that had an outcome

of aspiration risk (Behera 2018a; Daniels 1997; Daniels 2016a;

Daniels 2016b; Edmiaston 2010a; Edmiaston 2014a; Huhn-Matesic

2015; Lim 2001a; Lim 2001b; Nishiwaki 2005; Smith 2000; Trapl

2007b; Turner-Lawrence 2009; Warnecke 2008a; Warnecke 2008b),

and we found 20 (54.1%) that had an outcome of dysphagia

(Antonios 2010a; Antonios 2010b; Behera 2018b; Bravata 2009a;

Bravata 2009b; Campbell 2016; Cummings 2015; Edmiaston 2010b;

Edmiaston 2014b; Ellis 2013; Eren 2019; Huhmann 2004; Jiang

2019a; Jiang 2019b; Martino 2009 Study 1; Mulheren 2019; Perry

2001 Study 1a; Perry 2001 Study 1b; Perry 2001 Study 1c; Perry

2001 Study 1d). Only two (5.4%) narrative papers did not record the

outcome (Martino 2014; Zhou 2011).

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Methodological quality of included studies

Risk of bias

Results of the methodological quality assessment for each of the 25

included studies are shown in Figure 2. We considered six studies to

be at low risk across all four risk of bias domains: patient selection,

index test, reference standard, and flow and timing (Daniels 2016;

Lim 2001; Martino 2009 Study 1; Martino 2014; Trapl 2007; Warnecke

2008). Two studies were at low risk of bias for three domains (index

test, reference standard, and flow and timing) but at uncertain risk

for patient selection (Edmiaston 2014; Mulheren 2019).

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Figure 2.  Risk of bias and applicability concerns summary: review authors' judgements about each domain for each

included study.

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Figure 2.  (Continued)



A major concern for risk of bias across the other included studies

was that they had not enrolled consecutive patients. We identified

12 studies that had enrolled consecutive patients (Antonios 2010;

Daniels 1997; Daniels 2016; Jiang 2019; Lim 2001; Martino 2009

Study 1; Martino 2014; Nishiwaki 2005; Perry 2001 Study 1; Smith

2000; Trapl 2007; Warnecke 2008), but for 12 studies this was

unclear (Behera 2018; Bravata 2009; Campbell 2016; Cummings

2015; Edmiaston 2010; Edmiaston 2014; Ellis 2013; Eren 2019;

Huhmann 2004; Huhn-Matesic 2015; Mulheren 2019; Zhou 2011),

and one study employed a convenience sampling method (Turner-

Lawrence 2009). For 11 studies, it is unclear whether inappropriate

exclusions had been avoided when participants were recruited

(Behera 2018; Bravata 2009; Cummings 2015; Edmiaston 2010; Ellis

2013; Huhmann 2004; Huhn-Matesic 2015; Martino 2014; Perry 2001

Study 1; Turner-Lawrence 2009; Zhou 2011). Finally, it is unclear in

eight studies whether there had been an appropriate time interval

between the index test and the reference standard (Behera 2018;

Bravata 2009; Edmiaston 2010; Ellis 2013; Huhmann 2004; Huhn-

Matesic 2015; Perry 2001 Study 1; Zhou 2011), and it was reported

that the time interval was not appropriate in two studies (Daniels

1997; Nishiwaki 2005).

Applicability concerns

There were no applicability concerns for 15 studies across the three

applicability domains: patient selection, index test, and reference

standard (Antonios 2010; Bravata 2009; Daniels 2016; Edmiaston

2010; Edmiaston 2014; Eren 2019; Jiang 2019; Lim 2001; Martino

2009 Study 1; Martino 2014; Mulheren 2019; Perry 2001 Study 1;

Smith 2000; Trapl 2007; Warnecke 2008). However, concern was

high in five studies (Campbell 2016; Cummings 2015; Huhmann

2004; Nishiwaki 2005; Turner-Lawrence 2009), and concern was

unclear in four other studies (Behera 2018; Ellis 2013; Huhn-Matesic

2015; Zhou 2011), which included patients that did not match

the review question. Concern that the index test, its conduct, or

its interpretation diers from the review question was high in

Huhmann 2004 and unclear in four studies (Daniels 1997; Huhn-

Matesic 2015; Nishiwaki 2005; Zhou 2011).

Findings

Healthcare professionals’ level of training across studies

The level of training for healthcare professionals undertaking

the index test in dysphagia and/or use of the index test was

underreported, with only 21 of 37 screening tests stating that

training was oered. Of those that detailed the training, there was

variation in both length and content. Some index tests required 10

minutes of training (n = 4), some took several hours (n = 3), and

two detailed two days of training. The content of training varied

between training to use the test plus element of competence (n = 5),

instructions on how to use the index test (n = 4), instructions with

a practice component (n = 2), training in anatomy and physiology

of swallowing, identification and management of dysfunction and

five successful practice assessments (n = 2), on-line training in

swallowing anatomy and physiology (n = 1), clinical signs of

dysphagia and aspiration (n = 1), and digitised examples of five

stroke patients with a review of basic anatomy and physiology of

swallowing (n = 1). Some index tests reported that training was

oered but did not detail the contents (n = 5).

Synthesis of results

The high level of heterogeneity between studies as identified by

the review means that statistical pooling of diagnostic accuracy

data was not possible. We performed a descriptive analysis from

extracted data (2 × 2 tables) and sensitivity and specificity for all but

the four screening tests for which this data could not be extracted

(Eren 2019; Martino 2014; Nishiwaki 2005; Zhou 2011); these four

studies are not included from this point onwards.

Values for sensitivity and specificity presented here include

the point estimate (95% confidence interval (CI)). The criteria

of both high sensitivity and high specificity indicate that the

best performing test overall was the Standardized Swallowing

Assessment tool (SSA) (Perry 2001 Study 1d) (n = 68), which had

sensitivity of 0.97 (95% CI 0.86 to 1.00) and specificity of 0.90 (95%

CI 0.74 to 0.98). However, Perry 2001 Study 1 performed poorly

on the risk of bias assessment, showing, specifically, high risk of

bias in the flow and timing domain and unclear risk of bias in both

index test and reference standard domains, so this result should

be interpreted with caution. Several tests performed better on

sensitivity but less well on specificity: the Registered Dietician (RD)

Dysphagia Screening tool (n = 32) had sensitivity of 1.00 (95% CI

0.69 to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97) (Huhmann

2004); the Bedside Aspiration test (n = 50) had sensitivity of 1.00

(95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to 0.87)

(Lim 2001a); the Gugging Swallowing Screen (GUSS) (n = 30) had

sensitivity of 1.00 (95% CI 0.77 to 1.00) with specificity of 0.69 (95%

CI 0.41 to 0.89) (Trapl 2007b); and the Toronto Bedside Swallowing

Screening Test (TOR-BSST) (n = 24) had sensitivity of 1.00 (95% CI

0.75 to 1.00) with specificity of 0.64 (95% CI 0.31 to 0.89) (Martino

2009 Study 1).

Of the best performing screening tests, we have the most

confidence in the following studies: Bedside Aspiration test (Lim

2001a), GUSS (Trapl 2007b), and TOR-BSST (Martino 2009 Study 1),

which we rated as having low risk of bias across all four QUADAS-2

risk of bias domains. Of those with low risk of bias, the best

performing screening test using only water was TOR-BSST (Martino

2009 Study 1), and the best performing screening test using water

plus other consistencies was GUSS (Trapl 2007b). A description

of these tests is provided in Appendix 8. However, all of these

screening tools had small sample sizes (n < 100), which limits

interpretation of the estimates of reliability of these tests.

Screening tests were grouped into general categories according

to taxonomy (water only tests, water plus other consistencies

tests, and other tests), healthcare professionals who administered

the test (nurses versus other healthcare professionals), types of

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outcomes (aspiration versus dysphagia), and types of reference

standards (expert assessment or MASA versus VF versus FEES), and

we generated related summary receiver operating characteristic

(ROC) plots using RevMan 5 (see Figure 3; Figure 4; Figure 5; Figure

6). This informed the descriptive analysis, but no meta-analysis was

done because of the small number of studies identified for each

individual screening test.



Figure 3.  Summary ROC plot of tests: Grouped by Index taxonomy - water only, water plus bolus and other.

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Figure 4.  Summary ROC plot of tests grouped by index test healthcare professional - nurse and other.

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Figure 5.  Summary ROC plot of tests: grouping index tests by outcome - aspiration and dysphagia.

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Figure 6.  Summary ROC plot of tests: index tests grouped by reference test used - Expert Assessment, FEES and VS.



Type of test (water only tests versus water plus other

consistencies tests versus other tests)

Screening tools that used water and other consistencies (accuracy

ranged from sensitivity of 0.75 (95% CI 0.35 to 0.97) with specificity

of 0.89 (95% CI 0.75 to 0.97), to sensitivity of 1.00 (95% CI 0.69

to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97)) generally

were more accurate than screening tests that used only water

(accuracy ranged from sensitivity of 0.46 (95% CI 0.28 to 0.66) with

specificity of 1.00 (95% CI 0.83 to 1.00) to sensitivity of 1.00 (95%

CI 0.75 to 1.00) with specificity of 0.64 (95% CI 0.31 to 0.89)). Those

that used methods other than water only and water and other

consistencies had mixed results; some performed as well as the

water-only tests, with the most accurate scoring sensitivity of 1.00

(95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to 0.87))

(Figure 7). Others performed worse, with the least accurate scoring

having sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity of

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0.84 (95% CI 0.64 to 0.95)). Pooling of data by the screening test

taxonomy confirmed that screening tests that used water plus

other consistencies (participants n = 412) may be more sensitive

with similar or better specificity than screening tests that used

water only (participants n = 2914) or other methods (participants

n = 627) (Figure 3). However, only six tests used this method.

Screening tests that used only water had similar accuracy (in terms

of sensitivity and specificity) compared with screening tests using

other methods.



Figure 7.  Forest plot of tests grouped by Index Test Taxonomy - Water only, Water plus other consistencies, and

Other tests.



Type of reference standard (expert assessment or MASA versus

VF versus FEES)

Screening tools showed better agreement with expert assessment

or the MASA (accuracy ranged from sensitivity of 0.29 (95% CI 0.08

to 0.58) with specificity of 0.84 (95% CI 0.64 to 0.95) to sensitivity

of 1.00 (95% CI 0.69 to 1.00) with specificity of 0.86 (95% CI 0.65

to 0.97)) than they did with the instrument-based reference test

of FEES (accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to

0.61) with specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity

of 1.00 (95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49

to 0.87)) or VF (accuracy ranged from sensitivity of 0.46 (95%

CI 0.28 to 0.66) with specificity of 1.00 (95% CI 0.83 to 1.00) to

sensitivity of 1.00 (95% CI 0.75 to 1.00) with specificity of 0.64

(95% CI 0.31 to 0.89) (Figure 8). Pooling of screening tests by

reference test (Figure 6) confirmed that screening tests that used

expert assessment or the MASA (participants n = 2491) had the

highest accuracy. This may be expected, as the screening tests

will be more closely aligned to expert assessment methods than

to instrumental assessment. Screening tests that used VF as a

reference test had high sensitivity but lower specificity than those

using expert assessment or the MASA. However, the number of

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index tests compared to instrument-based reference tests was low: five were compared to FEES (participants n = 330) and eight were

compared to VF (participants n = 1132).



Figure 8.  Forest plot of tests grouped by Reference Test - Expert Assessment and MASA, FEES, and VF.



Type of primary outcome (aspiration versus dysphagia)

Screening tests with dysphagia as the primary outcome (accuracy

ranged from sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity

of 0.84 (95% CI 0.64 to 0.95) to sensitivity of 1.00 (95% CI 0.69 to 1.00)

with specificity of 0.86 (95% CI 0.65 to 0.97)) generally performed

better than screening tests for which the primary outcome was

aspiration (accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to

0.61) with specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity of

1.00 (95% CI 0.87 to 1.00) with specificity of 0.71 (95% CI 0.49 to

0.87)) (Figure 9). Pooling of screening tests by outcome (Figure 5)

showed that screening tests with the greatest accuracy, with both

high sensitivity and high specificity, had an outcome of dysphagia

(participants n = 2126). This was to be expected, as dysphagia is

more easily observed than aspiration. Several tests that detected

aspiration risk (participants n = 1827) had high sensitivity but

slightly lower specificity.

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Figure 9.  Forest plot of tests grouped by Index Test Outcome - aspiration and dysphagia.



Tests designed for nurses compared to tests designed for other

healthcare professionals

Screening tools carried out by nurses (accuracy ranged from

sensitivity of 0.29 (95% CI 0.08 to 0.58) with specificity of 0.84 (95%

CI 0.64 to 0.95) to sensitivity of 1.00 (95% CI 0.77 to 1.00) with

specificity of 0.69 (95% CI 0.41 to 0.89)) performed consistently

better than those carried out by other HCPs (excluding SLTs)

(accuracy ranged from sensitivity of 0.49 (95% CI 0.38 to 0.61) with

specificity of 1.00 (95% CI 0.82 to 1.00) to sensitivity of 1.00 (95% CI

0.69 to 1.00) with specificity of 0.86 (95% CI 0.65 to 0.97)) (Figure 10).

Generally, screening tests designed for use by nurses (participants

n = 2785) performed equally well as those designed for use by other

HCPs (excluding SLTs) (participants n = 1168) in terms of sensitivity

and specificity (Figure 4).

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Figure 10.  Forest plot of tests grouped by HCP - nurse and other.

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Other considerations

Screening tests with larger sample sizes (n > 200) were Behera

2018a, Behera 2018b, Daniels 2016a, Daniels 2016b, Edmiaston

2010a, Edmiaston 2010b, Edmiaston 2014a, and Edmiaston 2014b.

Of these, screening tests with the greatest accuracy (both high

sensitivity and high specificity) were Edmiaston 2010a, Edmiaston

2010b, and Edmiaston 2014b. All of these had narrow 95% CIs for

estimates of sensitivity and specificity. Their lower 95% CIs for

sensitivity had a higher value than for some of the overall best

performing tests - Lim 2001a, Trapl 2007b, and Martino 2009 Study

1. None of the tests with a larger sample size were assessed as low

risk for all four QUADAS-2 risk of bias (ROB) domains. Edmiaston

2010a and Edmiaston 2010b were unclear for three domains in the

ROB and were low for one domain. Edmiaston 2014b was unclear

for one domain in the ROB and was low for the other three domains.

In summary, even though 95% CIs for estimates of sensitivity and

specificity are narrower for the best performing screening tests,

which used a larger sample size, their QUADAS-2 risk of bias is not

as low as that for the overall best performing tests.

D I S C U S S I O N

Numerous variables need to be systematically reported regarding

training required by the healthcare professional undertaking the

swallow screening tool, consistencies oered as part of the tool,

and food and drink consistency management options available

to the person undertaking the test post screen. From a clinical

perspective, some bedside swallow screening tests are criticised

for making recommendations for consistencies that have not

been assessed. For example, water-only tests allow normal dietary

intake without assessment. Similarly water and other consistency

screening tests show a discrepancy between diet and fluid

consistencies tested and those recommended. Future studies

should take these concerns into consideration.

Summary of main results

This review aimed to summarise the evidence regarding accuracy

of swallow screening tests to detect aspiration risk associated

with dysphagia in acute stroke. Studies did not always report

suicient information regarding study characteristics; therefore, it

is not possible to explore the influence of sources of heterogeneity.

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Results show that a number of screening tools oered high

sensitivity. However, we were unable to identify a swallow

screening tool with concomitant high specificity. Furthermore, we

were unable to identify a diagnostically accurate swallow screening

tool that tests a variety of consistencies and oers immediate

management advice for healthcare settings that do not have the

facility to oer expert comprehensive assessments.

Population and setting

Although this review focused on acute stroke patients, some

studies did not define the time period (from stroke onset or from

admission) in which use of swallow screening tool was undertaken.

Owing to fluctuation in swallow function within a 24-hour period,

it is incumbent on researchers to specify the time period to

direct clinical practice (i.e. use of dierent screening tools at

dierent time periods post stroke) and to allow for comparisons of

sensitivity versus other studies. Screening tools that were used in

the outpatient setting or in the rehabilitation setting were excluded

from the review.

Index tests

The ideal balance of sensitivity and specificity may vary according

to the care setting. For example, a very sensitive screening test may

be appropriate for untrained sta who have professional backup

to rapidly identify false-positives. No screening test identified or

excluded swallowing diiculties with perfect accuracy. We were

able to identify tests with the best ability to detect people with

and without risk of aspiration from studies providing good quality

evidence. The best performing swallow screening tools were the

Bedside Aspiration test (Lim 2001a), the Gugging Swallowing

Screen (GUSS) (Trapl 2007b), and the Toronto Bedside Swallowing

Screening Test (TOR-BSST) (Martino 2009 Study 1). Although

screening tests with larger sample sizes (n > 200) had smaller

confidence intervals (CIs) in estimates of sensitivity and specificity,

they had higher risk of bias than the best performing tests so are

not among the recommended screening tests. For clinicians with a

variety of consistencies available, the best performing water plus

other consistencies test was GUSS (Trapl 2007b). Although GUSS

oers dierent consistencies as part of the assessment and oers

a consistency management plan for clinicians to implement, the

consistencies used are limited to puree, water, and solids, and

the test does not include all the consistencies identified in the

International Dysphagia Diet Standardised Initiative (International

Dysphagia Diet Std Initiative 2017). Therefore, this test may not

be suitable for implementation across all healthcare settings. The

best water-only swallow screening test was TOR-BSST (Martino

2009 Study 1). Although all tests demonstrate a combined highest

sensitivity and specificity and low risk of bias across all domains,

clinicians should be cautious in their interpretation of these

findings, as these tests are based on single studies with small

sample sizes, which limits the interpretation of estimates of

reliability for these screening tests.

Sensitivity is similar for tools with a primary outcome of dysphagia

or aspiration, but tools with dysphagia as their outcome perform

better in terms of specificity. This may be due to the greater number

of clinical signs of diiculty (e.g. chewing function) that may be

observed in dysphagia compared to aspiration, making it more

easily detected.

There is general agreement between index tests that some degree

of behavioural assessment (e.g. alertness), together with oromotor

assessment, was fundamental before progression to a test of oral

intake (either various sizes of water bolus or water plus various

consistencies). Generally, water plus various consistencies (n = 6)

performed better than water-only tools in terms of sensitivity and

specificity. The small number of index tests that did not use direct

patient assessment (e.g. used national stroke scales to identify risk

of swallowing diiculty) did not consistently perform well.

Only a few studies gave direction on what food and drink

consistencies should be given to an individual following the

screen (e.g. GUSS; Trapl 2007b). These studies will be useful in

healthcare settings, nationally and internationally, when an expert

assessment or an instrumental assessment is not available.

The best performing index tests are included in the group carried

out by nurses. Index tests carried out by other HCPs are less

consistent. This may be due to confounding factors regarding the

amount of training received by nursing sta within studies rather

than a reflection on the type of index test or professional group

undertaking the test. Of the 21 index tests undertaken by nurses, 17

(81.0%) recorded some form of training; for other HCPs, only four

(25.0%) papers reported a training element. Furthermore, papers

that reported training was required oen failed to present the

elements included in the training. In future studies, the type of

training delivered should be reported.

Reference standard

Reference tests were defined as either expert clinical assessments

(usually undertaken by speech and language therapists (SLTs))

or instrumental assessments. A variety of reference tests

were included to capture patients who could access dierent

instrumental assessments. However, the reliability of instrumental

assessments used to diagnostically identify aspiration is of clinical

concern.

Following the SLT opinion, we considered the Mann Assessment

of Swallowing Ability (MASA) as equivalent to an expert clinical

assessment and included the seven studies that used MASA as a

reference test. Tools that used the MASA or expert assessment for

reference testing had a better combined sensitivity and specificity

than tools that used instrumental tests of fibreoptic endoscopic

evaluation of swallowing (FEES) or videofluoroscopy (VF). This may

be due to the similarity between index tests and reference tests of

MASA/expert assessment in that both rely on clinical observations

rather than on instrumental assessment.

From summary receiver operating characteristic (SROC) plots,

which plot sensitivity versus (1-specificity), index tests that used

FEES as the reference test generally had higher sensitivity but

similar specificity than index tests that used VF or MASA as the

reference test combined with expert assessment. Most of the

studies that used FEES or VF report sensitivity greater than 85% but

poorer specificity than those that used MASA or expert assessments

as the reference test. No studies were compared to scintigraphy,

which remains mainly a research tool.

Quality of the evidence

The quality of evidence varied across included studies. The

most common reasons for reduced quality was considerable

heterogeneity between studies that aected our ability to combine

and directly compare results.

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Studies oen failed to distinguish between dysphagia and

aspiration as the primary outcome. Some did not routinely identify

time between stroke onset or admission to hospital and time the

screen was undertaken. Similarly, some studies failed to report

time between index test and reference test, and the swallow may

have improved or deteriorated in the interval between tests. Many

studies failed to report the training required by dierent healthcare

professionals to implement the screening tool.

Strengths and weaknesses of the review

Strengths

This DTA undertook the literature search from an International

perspective and included all relevant studies irrespective of

language of publication. Therefore we can be assured that no

relevant publications were excluded from our searches. We were

able to identify the best performing tools within each category of

swallow screening tools that used water alone, water plus other

bolus consistencies, and other methods. We included as narrative

studies trials that did not report statistical results.

Weaknesses

Apart from one screening tool that was assessed by two studies,

all remaining screening tools were assessed by single studies. This

hampered the possibility to perform any meaningful meta-analysis.

Only descriptive analyses grouped by general categories were

presented. Studies oen failed to distinguish between dysphagia

and aspiration as the primary outcome. Most studies had small

sample sizes, which limits interpretation of the estimates of

reliability of the screening tests. Some did not routinely identify

time between stroke onset or admission to hospital and time the

screen was undertaken. Similarly, some studies failed to report time

between the index test and the reference test, and the swallow

may have improved or deteriorated in the interval between tests.

Many studies failed to report the training required by dierent

healthcare professionals to implement the screening tool. This has

had an impact on the quality of this review. We performed no formal

assessment of the overall quality of the evidence, for example, by

using GRADE. We have not included any ongoing studies.

Applicability of findings to the review question

This review demonstrates that currently, high-quality evidence

from research is insuicient to provide conclusive results regarding

the accuracy of bedside swallow screening tools in identifying

aspiration associated with dysphagia in the acute stage of stroke.

Applicability of evidence

The review authors are aware of ongoing international studies

that are currently unpublished and are not included as part of

this review. However, this review does identify currently available

swallow screening tools that screen with water and those that

screen with a variety of consistencies to oer an ongoing food and

drink consistency management plan that may be implemented in

the clinical setting.

Implications for research

High-quality, appropriately statistically powered studies are

needed to evaluate the accuracy of a swallow screening tool in

identifying aspiration associated with dysphagia in acute stages of

stroke.

Future research studies should clearly define their primary

outcomes. They should provide more detail regarding participant

inclusion and exclusion criteria, and when a study includes

individuals with diering underlying aetiologies that precipitate

swallowing diiculties, these data should be reported separately.

Future studies should provide greater detail on participant location

and timing of the swallow screening tool used post stroke or

post admission. This, together with a description of participant

characteristics and swallow severity, would allow researchers to

identify the accuracy of a screening tool within dierent time

frames, revealing alterations in swallow function post stroke onset.

Studies should clarify the reference tests used, and when several

tests are undertaken, these should be reported separately.

The level of training provided to healthcare professionals

undertaking the index test in dysphagia and/or using the index

test has been underreported, and studies that detailed the training

show variation in both length and content of training. Future

research should detail the amount and content of training oered

and should examine the impact of training on study fidelity and

outcomes.

In addition to technical performance in accurately identifying

patients with dysphagia with its associated risk of aspiration,

bedside swallow screening tools should demonstrate clinical

utility. Evaluation of both short-term and long-term participant

outcomes at defined periods would facilitate assessment of

whether incidence of aspiration pneumonia, quality of life, and

participant mortality were influenced by timing of the screening

test post stroke or post admission.

Bedside swallow screening test cost-eectiveness data should

be reported to support healthcare services with clinical

implementation.

Future studies should apply the better performing screening tests

that we have identified, making minor changes in their design

to ensure that they have low Quality Assessment of Studies of

Diagnostic Accuracy (QUADAS-2) risk of bias and using larger

sample sizes, rather than continuing to develop local screening

tests. This would build up a body of evidence, would reduce

heterogeneity between screening tests, and ultimately would allow

a meta-analysis of dierent tests to be conducted.

Researchers should be encouraged to consider inclusion of these

issues to when performing future comparative studies.

Agreements and disagreements with other studies or reviews

This is the largest, most inclusive international and current review

on identification of risk of aspiration associated with dysphagia as

the main symptom of concern in the acute phase of stroke. Several

recent systematic reviews have explored the accuracy of screening

tools. However, these studies have limited the scope of their review

owing to the restricted range of languages accepted by the search

(Brodsky 2016; Daniels 2012; Jiang 2016; Oliveira 2001; Schepp

2012), the heterogeneity of included disorders (Brodsky 2016; Jiang

2016; O'Horo 2015), the paucity of information available regarding

the healthcare professional undertaking the study (Brodsky 2016;

Chen 2016; Daniels 2012; O'Horo 2015), comparison of only water

swallow tools (Brodsky 2016; Chen 2016), exclusion of instrumental

assessments from reference tests (Jiang 2016), consideration of

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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only dysphagia as the primary outcome (Jiang 2016; Oliveira 2001;

Schepp 2012), and specification that no training in dysphagia

should be required (Schepp 2012). However, this current review

had no language restrictions, focuses on acute stages of stroke,

identifies the range of healthcare professionals undertaking the

test, explores the diagnostic accuracy of tools including water

and water with other consistencies, and includes instrumental and

expert assessments as reference tests with aspiration associated

with dysphagia as the focus of the assessment. Therefore, direct

comparisons are diicult to make.

A U T H O R S '  C O N C L U S I O N S

Implications for practice

This review demonstrates that current high-quality evidence from

research is insuicient to provide conclusive results regarding the

accuracy of bedside swallow screening tools to identify aspiration

associated with dysphagia in the acute stage of stroke.

Implications for research

We have identified the need for high-quality research. Study

authors should be encouraged to include information regarding

patient demographics (including comorbidities that may impact

outcome and stroke location or classification) and definitions

regarding dysphagia and aspiration and time intervals (admission

to index test and time from index test to reference test). We

recommend that future studies should apply better performing

screening tests, enhanced to ensure they have low QUADAS-2 risk

of bias domains, and should use larger sample sizes.

A C K N O W L E D G E M E N T S

The review authors acknowledge the contributions of Brigit

Chesworth, Kerry Hannah, Dawn Doran, Janet Reed, Hazel Fraser,

and Josh Cheyne.

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SungHY, LeeKS, ChoiMG, KimJS. Dysphagia screening using

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JohansenAM, LindhardtT. Dysphagia screening and intensified

oral hygiene reduce pneumonia aer stroke. Journal of

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Tanuma 2002 {published data only}

TanumaS, SudoE, TakahashiY, YoshidaA, KobayashiC,

OhamaY. The usefulness of the water swallowing test and

videofluorography in swallowing rehabilitation in patients with

cerebrovascular disease. Nippon Ronen Igakkai Zasshi Japanese

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Teramoto 2000 {published data only}

TeramotoS, FukuchiY. Detection of aspiration and swallowing

disorder in older stroke patients: simple swallowing

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et al. Sapienza Global Bedside Evaluation of Swallowing aer

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Rehabilitation Sciences 2011;14(2):33-8.

Umay 2013 {published data only}

UmayE, UnluE, KilicG, CakciA, KorkmazH. Evaluation of

dysphagia in early period stroke patients by bedside screening

test, endoscopic and electrophysiological methods. Dysphagia

2013;28(3):395-403.

Virvidaki 2019 {published data only}

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WarneckeT, ImS, KaiserC, HamacherC, OelenbergS,

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WeinhardtJ, HazelettS, BarrettD, LadaR, EnosT, KelemanR.

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ZhangJ, WangYJ, CuiT. Reliability and validity of nine rating

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

C H A R A C T E R I S T I C S  O F  S T U D I E S

Characteristics of included studies [ordered by study ID]



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: AIS, diagnosed clinically by a neurologist; radi-

ographic (CT or MRI) confirmation of AIS

Exclusion criteria: unresolved dysphagia before stroke; history of

head/neck surgery or trauma that may impact swallowing ability;

any other concomitant neurological disorder that could impact

oropharyngeal swallowing ability

Setting: 1 × tertiary care academic medical centre with a certified

comprehensive stroke centre

Index tests Modified MASA (MMASA)

Target condition and reference standard(s) Dysphagia

MASA

Flow and timing All patients received the index test(s) and reference standard. All

patients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests ≤ 4 hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Antonios 2010

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Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? No  

Could the conduct or interpretation of the index test have

introduced bias?

 High risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Antonios 2010(Continued)



Study characteristics

Patient Sampling All patients were admitted under a standard stroke protocol

Patient characteristics and setting Inclusion criteria: patients admitted to a comprehensive stroke

centre

Exclusion criteria: unclear

Setting: 1 × hospital designated comprehensive stroke centre

Behera 2018

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Index tests The DePaul Hospital Swallow Screening tool includes a combina-

tion of non-swallow and swallow items. The 8 non-swallow items

(including tests of alertness, presence of a feeding tube, presence

of a tracheostomy tube, presence of drooling, facial asymmetry,

abnormal tongue movement, abnormal vocal quality, and abnor-

mal voluntary cough) are scored, and if patients pass (score ≤ 5),

they progresses onto the 3 oz WST. If patients fail the non-swal-

low items (score ≥ 6), or if they fail the WST (clinical signs of aspira-

tion), they are kept nil by mouth

Target condition and reference standard(s) Two analyses: dysphagia and aspiration risk

MASA

Flow and timing 374 were admitted to the stroke unit; 225 received the DHSS Index

test. The reason for the drop in numbers is not reported. 224 re-

ceived at least 1 MASA assessment 2 × 2 table is reported for 224

patients

Interventions between index/reference tests: not reported

Interval between index and reference tests: not reported

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Unclear

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Behera 2018(Continued)

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Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Unclear risk 

Behera 2018(Continued)



Study characteristics

Patient Sampling Patients who had received at least 1 Index test plus the reference

test

Patient characteristics and setting Inclusion criteria: discharge diagnosis with ischaemic stroke (ICD9

434.X and 436)

Exclusion criteria: none recorded

Setting: 1 × tertiary care - Department of Veterans Affairs Medical

Centre

Index tests Nurse Screening Tool applied during admission process. NIHSS

applied retrospectively

Target condition and reference standard(s) Dysphagia

SLP: expert assessment

Flow and timing Flow is not possible to report. Study reported only on those who

had at least 1 Index test + the reference test

Timing not reported. In fact, study authors list possible time differ-

ences as a limitation

Comparative 

Notes QUADAS-2 is different for each index test. Stroke Severity NIHSS

(test2) reported here, as it is the 'worst', compared to the Nurse

Screening Tool (test1)

Bravata 2009

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Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Unclear  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  High risk 

Bravata 2009(Continued)

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

Study characteristics

Patient Sampling Convenience sample

Patient characteristics and setting Inclusion criteria: diagnosis of stroke or TIA; admitted between

8:30am and 4:30pm; no change in initial NIHSS score between

screening by the nurse and evaluation by the speech pathologist

Exclusion criteria: non-stroke and non-TIA admissions; stroke

and TIA admissions after 4:30pm; NIHSS score change from initial

screening by the nurse, and subsequent evaluation performed by

speech pathologist

Setting: 1 × neuroscience unit - part of a Joint Commission Disease

Specific certified stroke centre

Index tests NBDS

Target condition and reference standard(s) Dysphagia

SLP: expert assessment

Flow and timing 3 patients not screened by Nurse 2

Interventions between index/reference tests: not reported

Interval between index and reference tests: < 1 hour

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  High

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Campbell 2016

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Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Unclear  

Could the patient flow have introduced bias?  Unclear risk 

Campbell 2016(Continued)



Study characteristics

Patient Sampling Convenience sample

Patient characteristics and setting Inclusion criteria: medical diagnosis of stroke; age 18 or older;

ability to follow commands

Exclusion criteria: individuals who were NPO for any reason other

than swallowing problems; history of previous swallowing prob-

lems; mechanical ventilation and/or intubation longer than 24

hours during current admission; inability to follow commands

Setting: 2 × hospital - 20-bed medical neurology unit and 9-bed

neurology intermediate care unit

Index tests Nurse dysphagia screen

Target condition and reference standard(s) Dysphagia

Dysphagia evaluation by SLP

Flow and timing All patients received index test(s) and reference standard. All pa-

tients were included in 2 × 2 table

Interventions between index/reference tests: not reported

Cummings 2015

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Index to reference tests interval: ≤ 2 hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  High

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? No  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Unclear

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Cummings 2015(Continued)

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Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Cummings 2015(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: new neurological deficit; stroke confirmed by

documentation of acute infarct by CT or MRI scan

Exclusion criteria: obtunded and agitated patients; those with pri-

or history of oropharyngeal dysphagia, oropharyngeal structural

damage, or neurological disease other than stroke that may pro-

duce dysphagia

Setting: 1 × Veterans Affairs Medical Center in New Orleans

Index tests Oropharyngeal assessment to include clinical swallowing assess-

ment

Target condition and reference standard(s) Dysphagia severity or risk of aspiration

VSS

Flow and timing All patients received index test(s) and reference standard. All pa-

tients included in 2 × 2 table apparently, but numbers do not real-

ly add up

Interventions between index/reference tests: not reported

Average time between test: 48 hours

Comparative 

Notes Flow and timing high risk due to 48-hour average time gap

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Daniels 1997

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Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Unclear  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Unclear

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

No  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  High risk 

Daniels 1997(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: suspected stroke

Exclusion criteria: non-stroke neurological disease; head/neck

structural changes; dysphagia unrelated to stroke; TIA/stroke

ruled out; not competent/no legally authorised representative;

medically unstable; repeat stroke; previously participated in the

study; > 3 weeks from symptom onset; > 5 days from admission;

childbearing potential female; deceased

Setting: 1 × Michael E DeBakey Veterans Affairs Medical Center –

comprehensive stroke centre

Index tests RAS3 and WST from RAS3

Target condition and reference standard(s) Aspiration in patients with suspected stroke

Daniels 2016

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VFSS

Flow and timing 8 patients who received the index test were not reported on. Rea-

sons for no VFSS included C-spine surgery evident on X-ray (n = 1)

and no oral intake before surgery (n = 1)

Reasons for exclusion from VFSS analyses included dysphagia his-

tory prior to stroke (n = 2), equipment failure (n = 1), and C-spine

damage (n = 3)

Interventions between index/reference tests: not reported

Index to reference test time interval within 2 hours of screening;

mean (SD) 0.49 (0.24) hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Daniels 2016(Continued)

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Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? No  

Could the patient flow have introduced bias?  Low risk 

Daniels 2016(Continued)



Study characteristics

Patient Sampling Not recorded

Patient characteristics and setting Inclusion criteria: admitted to stroke service

Exclusion criteria: none recorded

Setting: 1 × Stroke Service at Barnes-Jewish Hospital, Washington

University Medical Centre

Index tests ASDS

Target condition and reference standard(s) Aspiration risk and dysphagia

MASA

Flow and timing All patients received index test(s) and reference standard. All pa-

tients included in 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests: approximately 24 hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Edmiaston 2010

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Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Unclear  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Unclear risk 

Edmiaston 2010(Continued)



Study characteristics

Patient Sampling Acute stroke patients prospectively enrolled from Barnes-Jewish

Hospital inpatient stroke service (p2)

Patient characteristics and setting Inclusion criteria: clinical diagnosis of stroke (ischaemic or haem-

orrhagic); age ≥ 18 years

Exclusion criteria: decreased level of alertness preventing partic-

ipation in VFSS (defined as a score of 2 on the 'Alertness' compo-

nent of the MASA); physical limitations preventing ability to sit up-

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right (excluding intubation, or if treating physician had ordered

the patient to have the head of the bed flat); confirmed or suspect-

ed pregnancy

Setting: 1 × Barnes-Jewish Hospital inpatient stroke service (ur-

ban, tertiary care referral centre admitting 1300 stroke patients

annually)

Index tests BJH-SDS

Target condition and reference standard(s) Dysphagia and aspiration

VFSS

Flow and timing Study included 2 tests: 1 for dysphagia and 1 for aspiration. For

the dysphagia test, all patients received the reference test; for the

aspiration test, 2 patients were excluded and did not receive the

reference test

Interventions between index/reference tests: not reported

Interval between index and reference test: 0 to 8 hours (mean in-

terval 2 hours)

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

Edmiaston 2014(Continued)

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DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Unclear  

Could the patient flow have introduced bias?  Low risk 

Edmiaston 2014(Continued)



Study characteristics

Patient Sampling Not recorded

Patient characteristics and setting Inclusion criteria: patient suffered stroke or TIA

Exclusion criteria: not recorded

Setting: 1 × small community hospital - certified primary stroke

centre

Index tests Ellis Nursing Bedside Swallowing Screen

Target condition and reference standard(s) Dysphagia

Complete dysphagia evaluation by SLT

Flow and timing 53 participants were included, baseline data for 49 participants

are given, and 46 participants received both screening tests. Out-

line data are provided for patients who were excluded or with-

drawn; however numbers do not necessarily specify the difference

between original sample and those receiving the tests

Interventions between index/reference tests: not reported

Interval between tests: not reported

Comparative 

Notes 

Ellis 2013

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Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Unclear

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Unclear  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

No  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 High risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Unclear

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Unclear  

Were all patients included in the analysis? No  

Could the patient flow have introduced bias?  High risk 

Ellis 2013(Continued)

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

Study characteristics

Patient Sampling Unclear

Patient characteristics and setting Inclusion criteria: diagnosis of acute stroke based on clinical and MRI

results; aged > 18 years; normal cognitive function (Mini-Mental Test

Score > 24 points)

Exclusion criteria: presence of previous stroke; neurodegenerative or

muscular disease history potentially associated with swallowing disor-

der; malignancy; history of surgery in the head and neck region; bilat-

eral cranial infarction; psychiatric disorder; presence of infectious dis-

ease such as HIV, hepatitis B or C, decompensated heart failure, and

nasal obstruction (exclusion criteria for FEES)

Setting: 1 × neurology department

Index tests Turkish version of BJH-SDS consists of 5 items, each with 2 choices

(i.e. present = yes, absent = no). The first 4 items assess conscious-

ness and asymmetry or weakness in facial, tongue, and palatal mus-

cles. Level of consciousness is assessed by the Glasgow Coma Scale,

and presence of dysarthria is identified together with the use of other

items. The fih item consists of the 3-oz water test, and the abnormal-

ity was defined as coughing, choking, or breathlessness while swal-

lowing, or wet/gurgled voice after swallowing. The screening tool is a

pass/fail

Target condition and reference standard(s) Dysphagia

FEES

Flow and timing It is not clear whether the same number of patients received index and

reference tests

2 × 2 table: not reported

Interventions between index/reference test: not reported

Interval between tests: ≤ 24 hours

Comparative 

Notes 

Methodological quality

Item Authors' judgement Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Eren 2019

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Are there concerns that the included patients and set-

ting do not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge

of the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test

have introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or in-

terpretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the tar-

get condition?

Yes  

Were the reference standard results interpreted without

knowledge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its inter-

pretation have introduced bias?

 Low risk 

Are there concerns that the target condition as defined

by the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and

reference standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Unclear  

Could the patient flow have introduced bias?  Unclear risk 

Eren 2019(Continued)



Study characteristics

Patient Sampling Convenience sample

Patient characteristics and setting Inclusion criteria: none recorded

Exclusion criteria: none recorded

Setting: 1 × admitted to the stroke team

Index tests Registerd Dietician Dysphagia Screening Tool

Target condition and reference standard(s) Dysphagia risk

Huhmann 2004

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SLT bedside swallow assessment

Flow and timing All patients received index test(s) and reference standard. All pa-

tients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests: not reported

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  High risk 

Are there concerns that the included patients and setting do

not match the review question?

  High

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Unclear  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  High

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Huhmann 2004(Continued)

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Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  High risk 

Huhmann 2004(Continued)



Study characteristics

Patient Sampling Unclear

Patient characteristics and setting Regional non-critical care stroke unit. Patient inclusion and exclu-

sion criteria not reported

Index tests EHMBAS followed by simple WST; interpretation not reported

Target condition and reference standard(s) MASA

Flow and timing All patients received the index test(s) and reference standard. All

patients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests: not reported

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Unclear

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

Huhn-Matesic 2015

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If a threshold was used, was it pre-specified? Unclear  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Unclear

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Unclear  

Could the patient flow have introduced bias?  Unclear risk 

Huhn-Matesic 2015(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: diagnosis of stroke, clinical diagnosis from a neurologist,

radiographic (CT or MRI) confirmation of stroke

Exclusion criteria: history of head/neck surgery, trauma; brain tumour that

could influence swallowing abilities; any other concomitant neurological

disorder that could influence oropharyngeal swallowing ability

Setting: 1 × neurology unit

Index tests The 8-item Chinese version of the modified Standardized Swallowing As-

sessment instrument is divided into 2 parts. In part 1, patients must (1) vol-

untarily cough, (2) control saliva, (3) lick top and bottom lips, (4) breathe

freely, and (5) cannot have a wet or hoarse voice. In part 2 (items 6 to 8), pa-

tients are first given 1 mL of water. Problems are identified if no attempts

are made to swallow or water leaks straight out of the mouth, if coughing,

choking, or breathlessness is observed, or if a wet/gurgly voice develops. In

the absence of any problems, the process is repeated with second and third

tests with 1 mL of water. Gradually, increasing volumes ranging from 1 to 10

mL sequential swallowing are used based on patient tolerance. If no prob-

Jiang 2019

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lems are evident, half a glass of water (75 mL) is administered. The screen-

ing instrument is a pass vs fail procedure

The 6-item Chinese version of the modified Standardized Swallowing As-

sessment includes the following items from the 8-item instrument: items 1,

3, and 5 of the oromotor examinations, and items 6, 7, and 8 of the WST

Target condition and reference standard(s) Dysphagia

SLP expert assessment

Flow and timing All patients received both index and reference tests. All patients were in-

cluded in the analysis

Interventions between index/reference tests: none reported

Interval between tests: ≤ 48 hours

Comparative 

Notes 

Methodological quality

Item Authors' judgement Risk of bias Applicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients en-

rolled?

Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced

bias?

 Low risk 

Are there concerns that the included patients and

setting do not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowl-

edge of the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? No  

Could the conduct or interpretation of the index

test have introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct,

or interpretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify

the target condition?

Yes  

Jiang 2019(Continued)

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Were the reference standard results interpreted with-

out knowledge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its in-

terpretation have introduced bias?

 Unclear risk 

Are there concerns that the target condition as de-

fined by the reference standard does not match the

question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test

and reference standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Jiang 2019(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: acute stroke patients admitted to stroke unit of

Tan Tock Seng Hospital

Exclusion criteria: severe peripheral vascular disease; conscious-

ness level not sufficient to give informed consent; no CT evidence

of stroke or no significant neurological deficit (e.g. new hemiple-

gia) lasting > 24 hours; insufficient lip seal to retain 10 mL of water

in the mouth

Setting: 1 × stroke unit

Index tests WST and bedside aspiration (combined WST and oxygen satura-

tion test)

Target condition and reference standard(s) Aspiration

FEES

Flow and timing Patient flow is unclear - 58 patients were eligible, 50 patients re-

ceived reference and index tests, 8 patients subsequently declined

FEES

Interventions between index/reference tests: not reported

Time interval between tests: < 24 hours for 45 patients; < 48 hours

for 5 people due to 'technical issues'

Comparative 

Notes 

Methodological quality

Lim 2001

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Lim 2001(Continued)



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Study characteristics

Patient Sampling Consecutive. However 1 in 5 patients receiving a negative screen and

all receiving a positive screen on the index test received the refer-

ence test

Patient characteristics and setting Inclusion criteria: newly admitted to hospital; confirmed diagnosis of

brain stem stroke or cerebellar stroke and all other stroke types with

NIHSS score ≥ 4; stroke confirmed from physician’s clinical note, CT

scan or MRI

Exclusion criteria: non-brain stem and non-cerebellar stroke patients

with low NIHSS scores; patients with current respiratory compro-

mise; a non-oral feeding regime; history of non-stroke neurological

disorder; surgery to the head or neck; history of previous oropharyn-

geal dysphagia, dementia, or decreased level of consciousness; not

alert; cannot be supported to sit upright; cannot follow simple in-

structions

Setting: 2 acute settings will be used for analysis, originally 4. Inpa-

tient stroke units at 2 acute (used in data extract) and 2 rehabilitation

tertiary care hospitals (not used in data extract) in southern Ontario

Index tests TOR-BSST

Target condition and reference standard(s) Dysphagia risk

Videofluoroscopic assessment of swallowing

Flow and timing Of the 311 patients recruited, only 103 were from an acute setting,

and of these only 24 received both tests. Remaining patients were

therefore excluded from the analysis

Interventions between index/reference tests: not reported

Interval between tests ≤ 24 hours

Comparative 

Notes 

Methodological quality

Item Authors' judgement Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting

do not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Martino 2009 Study 1

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Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or in-

terpretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the tar-

get condition?

Yes  

Were the reference standard results interpreted without

knowledge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpre-

tation have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and

reference standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? No  

Could the patient flow have introduced bias?  Low risk 

Martino 2009 Study 1(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: eligible and consented stroke patients in the

original study

Exclusion criteria: not reported

Setting: 2 × acute and 2 × rehabilitation facilities

Index tests TOR-BSST

Target condition and reference standard(s) Dysphagia

VFSS

Martino 2014

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Flow and timing All patients recruited received both index and reference tests. All

patients were included in the analysis, but no 2 × 2 table was re-

ported

Interventions between index/reference tests: none reported

Interval between tests < 24 hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Martino 2014(Continued)

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Martino 2014(Continued)



Study characteristics

Patient Sampling Acute stroke patients admitted to the unit

Patient characteristics and setting Inclusion criteria: acute stroke patients on the units

Exclusion criteria: history of swallowing dysfunction or neurological dis-

ease that might lead to swallowing dysfunction; medical compromise

barring transport to fluoroscopy; insufficient level of alertness to follow

directions during VFSS as determined by the care team

Setting: 1 × neuroscience critical and acute care units of a tertiary care fa-

cility

Index tests The Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow

Screen is based on the 3-oz water swallow test by DePippo 1992. The

screen consists of 3 steps: (1) medical history and status; (2) 1 tsp water

swallow with palpation for hyolaryngeal excursion and observation for

signs of aspiration; (3) 3 oz water swallow with palpation for hyolaryn-

geal excursion and observation for signs of aspiration. Observation for

signs of aspiration is continuous during and up to 1 minute after each

water trial. Wet vocal quality is assessed objectively during the vocalisa-

tion trial by trained nurses. Each step is administered sequentially, and

failure of 1 step results in discontinuation and failure of the entire screen

(positive aspiration risk) with nil-by-mouth status and referral to speech

and language pathology for bedside evaluation

Target condition and reference standard(s) Dysphagia

VFSS

Flow and timing All patients recruited received both index and reference tests. All patients

were included in the analysis

Interventions between index/reference tests: none reported

Interval between tests < 72 hours

Comparative 

Notes 

Methodological quality

Item Authors' judgement Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Mulheren 2019

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Was a consecutive or random sample of patients en-

rolled?

Unclear  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and set-

ting do not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowl-

edge of the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test

have introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or

interpretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the

target condition?

Yes  

Were the reference standard results interpreted without

knowledge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its inter-

pretation have introduced bias?

 Low risk 

Are there concerns that the target condition as de-

fined by the reference standard does not match the

question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test

and reference standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Mulheren 2019(Continued)



Study characteristics

Nishiwaki 2005

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Patient Sampling Consecutive patients

Patient characteristics and setting Inclusion criteria: stroke was diagnosed with CT or MRI. Patients

presented with ≥ 1 of the following: (1) bilateral or brain stem

stroke; (2) history of aspiration pneumonia or increased sputum

secretion; (3) cough associated with feeding and/or drinking; (4)

weight loss, decreased oral intake, or prolonged feeding times; (5)

complaint of difficulty in swallowing; (6) need for a therapeutic di-

et or non-oral feeding

Exclusion criteria: patients who could not follow commands, who

had a tracheostomy, who had a prior history of oropharyngeal im-

pairment, or who had active respiratory infection

Setting: 5 × university hospital and affiliated hospitals

Index tests Clinical swallowing tests: 6 oromotor examinations

Target condition and reference standard(s) Aspiration

VFSS

Flow and timing All patients recruited received both index and reference tests. All

patients were included in the analysis

Interventions between index/reference tests: none reported

Interval between tests < 7 days, but < 24 hours for acute patients

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  High

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Unclear  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Nishiwaki 2005(Continued)

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Unclear

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

No  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  High risk 

Nishiwaki 2005(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: admissions with a clinical diagnosis of acute

stroke (ICD 10 codes 160-164, with or without CT confirmation)

Exclusion criteria: none recorded

Setting: 1 × study wards of Mayday University Hospital (all wards

that normally care for stroke patients with the exception of 2

female care of the elderly wards where another project was in

progress)

Index tests Standardized Swallowing Assessment tool (test 1)

Standardized Swallowing Assessment tool (test 2) (subset of test

Gag reflex (test 3) (subset of test 4)

Gag reflex data from the 20-month audit period used (test 4)

Target condition and reference standard(s) Dysphagia

Summative clinical judgement - used VFS when requested by SLT

to clarify decision

Perry 2001 Study 1

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Flow and timing Flow of patients is unclear from the paper. Although participants

are discussed in the paper, results are presented as episodes. The

results also include repeat screenings for participants; partici-

pants are excluded after recruitment and are not included in the

analysis

Interventions between index/reference tests: not reported

Interval between tests: not reported

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Unclear  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Perry 2001 Study 1(Continued)

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Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Did all patients receive the same reference standard? No  

Were all patients included in the analysis? No  

Could the patient flow have introduced bias?  High risk 

Perry 2001 Study 1(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: acute haemorrhagic or infarctive stroke; stroke

confirmed by CT scan; age 18 to 90 years

Exclusion criteria: impaired consciousness level; cognitive impair-

ment or receptive dysphasia sufficient to prevent informed con-

sent; inability to sit upright without minimal support; current low-

er respiratory infection; additional neurological condition; termi-

nal illness; any medical condition that precluded VF

Setting: 2 × university teaching hospitals in Manchester

Index tests Smith Bedside Swallowing, pulse oximetry (Minolta Pulsox 7), or

both

Target condition and reference standard(s) Aspiration and penetration

Flow and timing All patients received the index test(s) and the reference standard.

All patients were included in the 2 × 2 table, but for tests 1 and 5,

the 2 × 2 was recovered in the RevMan calculator. This gave test 5

with N = 52, 1 patient missing

Interventions between index/reference tests: not reported

Interval between tests ≤ 24 hours (all tests carried out on the same

day)

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Smith 2000

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Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Unclear  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Smith 2000(Continued)



Study characteristics

Patient Sampling Consecutive

Trapl 2007

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Patient characteristics and setting Inclusion criteria: patients with first-ever acute stroke and sus-

pected dysphagia; admitted to the acute stroke unit on weekdays

between Monday and Thursday

Exclusion criteria: multiple infarcts visible on CT or MRI scan; dys-

phagia of other known cause; somnolence or coma within 24

hours

Setting: 1 × acute stroke unit

Index tests GUSS

Target condition and reference standard(s) Aspiration

FEES

Flow and timing In group 1, 1 patient refused FEES (reference test) and so was not

included in the 2 × 2 table

In group 2, all patients received the index test(s) and the reference

standard. All patients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests < 24 hours

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

Trapl 2007(Continued)

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DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? No  

Could the patient flow have introduced bias?  Low risk 

Trapl 2007(Continued)



Study characteristics

Patient Sampling Convenience sample

Patient characteristics and setting Inclusion criteria: presumptive stroke diagnosis; age ≥ 18 years;

presenting to the emergency department within 24 hours of symp-

tom onset; Glasgow Coma Scale score > 12; hospital admission

Exclusion criteria: non-stroke diagnosis (based on admitting or

consultant physician evaluation); primary brain lesion as cause of

stroke; intubation before completion of ED screening or SLP eval-

uation; history of dysphagia or modified feeding route; pre-exist-

ing neuromuscular disorder; history of head and neck cancer or

radiation; preexisting pneumonia on ED chest radiography; preg-

nancy

Setting: 1 × 850-bed, tertiary-care, TJC-certified, primary stroke

centre located in the southeast

Index tests ED dysphagia screen (2-tiered approach)

Target condition and reference standard(s) Aspiration

SLP dysphagia assessment

Flow and timing All patients received the index test(s) and the reference standard.

All patients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests ≤ 24 hours

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Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? No  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  High risk 

Are there concerns that the included patients and setting do

not match the review question?

  High

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Unclear  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Turner-Lawrence 2009(Continued)

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Could the patient flow have introduced bias?  Low risk 

Turner-Lawrence 2009(Continued)



Study characteristics

Patient Sampling Consecutive

Patient characteristics and setting Inclusion criteria: first-ever stroke; admitted within 24 hours of

onset of symptoms; patients eligible for advanced dysphagia as-

sessment as defined by NIHSS score ≥ 3 points and/or who had to

present with facial palsy and/or dysarthria

Exclusion criteria: patients with history of a pre-existing dysphagia

or disease probably causing dysphagia; severely reduced state of

consciousness (i.e. stupor or coma)

Setting: not recorded

Index tests 2-step Swallowing Provocation Test

Target condition and reference standard(s) Aspiration

FEES

Flow and timing All patients received the index test(s) and the reference standard.

All patients were included in the 2 × 2 table

Interventions between index/reference tests: not reported

Interval between tests ≤ 24 hours, reported as immediately follow-

ing

Comparative 

Notes 

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Yes  

Did the study avoid inappropriate exclusions? Yes  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Low risk 

Are there concerns that the included patients and setting do

not match the review question?

  Low concern

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Yes  

Warnecke 2008

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If a threshold was used, was it pre-specified? Yes  

Could the conduct or interpretation of the index test have

introduced bias?

 Low risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Low concern

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Yes  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Yes  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Low risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Low concern

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Yes  

Did all patients receive the same reference standard? Yes  

Were all patients included in the analysis? Yes  

Could the patient flow have introduced bias?  Low risk 

Warnecke 2008(Continued)



Study characteristics

Patient Sampling Unclear

Patient characteristics and setting Inclusion criteria: patients suffering a first-ever hemispheric

stroke; symptoms lasting at least 24 hours; objective lesions on

cerebral imaging (CT and/or MRI) confirmed

Exclusion criteria: patients with subarachnoid haemorrhage, sub-

tentorial stroke or TIA, patients with sufficient loss of conscious-

ness to prevent oral feeding; patients with history of otolaryngo-

logical cancer; < 18 years of age; those who did not expressly agree

to participate in the study

1 × Neurology Department at university hospital. 1 × Department

of Physical Medicine and Readaptation

Index tests Clinical Predicative Scale of Aspiration; Practical Aspiration

Screening Scheme

Zhou 2011

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Target condition and reference standard(s) Reference standard: videofluoroscopic examination

Flow and timing 

Comparative 

Notes This paper is classified as narrative

Methodological quality

Item Authors' judge-

ment

Risk of bias Applicability con-

cerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled? Unclear  

Did the study avoid inappropriate exclusions? Unclear  

Was a two-gate design avoided? Yes  

Could the selection of patients have introduced bias?  Unclear risk 

Are there concerns that the included patients and setting do

not match the review question?

  Unclear

DOMAIN 2: Index Test (All tests)

Were the index test results interpreted without knowledge of

the results of the reference standard?

Unclear  

If a threshold was used, was it pre-specified? Unclear  

Could the conduct or interpretation of the index test have

introduced bias?

 Unclear risk 

Are there concerns that the index test, its conduct, or inter-

pretation differ from the review question?

  Unclear

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target

condition?

Unclear  

Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Unclear  

Could the reference standard, its conduct, or its interpreta-

tion have introduced bias?

 Unclear risk 

Are there concerns that the target condition as defined by

the reference standard does not match the question?

  Unclear

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and refer-

ence standard?

Unclear  

Zhou 2011(Continued)

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Did all patients receive the same reference standard? Unclear  

Were all patients included in the analysis? Unclear  

Could the patient flow have introduced bias?  Unclear risk 

Zhou 2011(Continued)

AIS: acute ischaemic stroke.

ASDS: Acute Stroke Dysphagia Screening.

BJH-SDS: Barnes-Jewish Hospital-Stroke Dysphagia Screen.

CT: computed tomography.

ED: emergency department.

EHMBAS: Edith-Huhn-Matesic Bedside Aspiration Screen.

FEES: fibreoptic endoscopic evaluation of swallowing.

GUSS: Gugging Swallowing Screen.

MASA: Mann Assessment of Swallowing Ability.

MRI: magnetic resonance imaging.

NBDS: Nursing Bedside Dysphagia Screen.

NIHSS: National Institutes of Health Stroke Scale.

NPO: nil by mouth.

RAS3: Rapid Aspiration Screening for Suspected Stroke.

SLP: speech and language pathologist.

SLT: speech and language therapist.

TIA: transient ischaemic attack.

TOR-BSST: Toronto Bedside Swallowing Screening Test.

VF: videofluoroscopy.

VFSS: videofluoroscopic swallowing study.

WST: water-swallowing test.



Characteristics of excluded studies [ordered by study ID]



Study Reason for exclusion

Addington 1999 Study 1 No acute stroke

Addington 1999 Study 2 No acute stroke

Alsibai 2014 No outcome of interest

Anderson 2016 Does not compare tests

Archer 2015 Study 1 No index or reference test of interest

Archer 2015 Study 2 No index or reference test of interest

Armesto 2015 No outcome of interest

Aviv 1997 No outcome of interest

Aydogdu 2015 Not limited to stroke patients

Babi 2014 Does not compare tests

Bahia 2014 Does not compare tests

Bahia 2016 Not an acute setting

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Study Reason for exclusion

Bax 2013 Does not compare tests

Bax 2014 No index or reference test of interest

Benjamin 2015 Not a single-gate or 2-gate study

Burks 2011 No screening for dysphagia

Carnaby 2014 No index or reference test of interest

Carrington 2013 Does not compare tests

Chavarria 2015 No screening for dysphagia

Choi 2010 No index or reference test of interest

Chong 2003 Not an acute setting

Cichero 2009 Not limited to stroke patients

Clayton 2006 No index or reference test of interest

Collins 1997 Not an acute setting

Crary 2013 Study 1 No index or reference test of interest

Crary 2013 Study 2 No index or reference test of interest

Crary 2014 Study 1 No index or reference test of interest

Crary 2014 Study 2 No index or reference test of interest

Daniels 2009 Does not compare tests

Davis-De Geus 2009 No outcome of interest

DePippo 1992 Not an acute setting

Farneti 2015 Index test undertaken by experts

Giraldo-Cadavid 2015 No outcome of interest

Guerra 2011 Does not compare tests

Guillén-Solà 2011 No screening for dysphagia

Guillén-Solà 2013 Not an acute setting

Gurcay 2018 Sample not restricted to acute stages of stroke

Higo 2003 No index or reference test of interest

Joundi 2017 Not a single-gate or 2-gate study

Karaca 2018 Reference test MASA considered an SLT dysphagia assessment

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Study Reason for exclusion

Logemann 1999 Not limited to stroke patients

Mandysova 2015 Not limited to stroke patients

Marques 2008 Does not compare tests

Martino 2009 Study 2 No index or reference test of interest

Massey 2002 Not all patients received the same reference test

McCullough 2001 SLT dysphagia assessment, not screening

McCullough 2005 No acute stroke

Moalli 2016 Does not compare tests

Moon 2010 No consecutive stroke patients

Mozzanica 2017 Heterogeneous population. Stroke not analysed separately

Murray 2011 No outcome of interest

NCT00306501 No accuracy of screening

NCT00580138 No index or reference test of interest

NCT01765673 No accuracy of screening

NCT02080988 No outcome of interest

NCT02848664 Not limited to stroke patients

NCT03167892 No accuracy of screening

Nomura 2014 Does not compare tests

Oh 2016 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated

Ohira 2013 Not limited to stroke patients

Ohira 2017 Not an acute setting

Osawa 2013 No consecutive stroke patients

Ostrofsky 2016 Index tests carried out by SLT/SLP

Palli 2017 No reference test performed on same patients who had nurse swallow screen – the compari-

son was with case note data from historic SLT assessment

Pennsylvania Patient Safety Author-

ity 2009

Not limited to stroke patients

Perry 2000 Does not compare tests

Perry 2001 Study 2 Does not compare tests

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Study Reason for exclusion

Radhakrishnan 2013 No screening for dysphagia

Rosenbek 2004 SLT dysphagia assessment, not screening

Sato 2012 Not an acute setting

Schrock 2011 No index or reference test of interest

Sellars 1998 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated

Smith Hammond 2009 Index tests carried out by SLT/SLP

Sohn 2018 Reference test is a retrospective evaluation of case records

Soria 2013 Not limited to stroke patients

Stroke and Chewing 2012 No outcome of interest

Sung 2018 Does not compare tests

Sørensen 2013 Does not compare tests

Tanuma 2002 Not screening for dysphagia

Teramoto 2000 Not an acute setting

Toscano 2019 Index test undertaken by experts

Tuncay 2011 Not index or reference test of interest

Umay 2013 No acute stroke

Virvidaki 2019 Index test undertaken by experts

Warnecke 2017 Index tests carried out by SLT/SLP

Weinhardt 2008 Does not compare tests

Ye 2018 No reference test was included

Yeh 2011 Does not compare tests

Zhang 2004 All patients had dysphagia or aspiration; therefore sensitivity/specificity cannot be calculated

MASA: Mann Assessment of Swallowing Ability.

SLP: speech and language pathologist.

SLT: speech and language therapist.



D A T A

Presented below are all the data for all of the tests entered into the review.



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Table Tests.  Data tables by test

Test No. of studies No. of participants

1 Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004) 1 32

2 Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001) 1 50

3 Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007) 1 30

4 Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009) 1 24

5 Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2 1 68

6 Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016) 1 75

7 Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009) 1 84

8 Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010) 1 300

9 Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Ed-

miaston (2014)

1 223

10 Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swal-

low test - Huhn-Matesic (2015)

1 52

11 Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001) 1 161

12 Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia -

Edmiaston (2014)

1 225

13 Modified MASA (MMASA) Neurologist 1 - Antonios (2010) 1 150

14 Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016) 1 250

15 Clinical examination - Daniels (1997) 1 59

16 Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010) 1 300

17 Nurse Dysphagia Screen - Cummings (2015) 1 49

18 Modified MASA (MMASA) Neurologist 2 - Antonios (2010) 1 150

19 Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000) 1 53

20 Bedside swallow test - WST only - Lim (2001) 1 50

21 Chinese version of the modified SSA original 8 items - Jiang (2019) 1 127

22 Chinese version of the modified SSA reduced 6 items - Jiang (2019) 1 127

23 Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) -

Bravata (2009)

1 101

24 Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013) 1 46

25 2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008) 1 100

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Test No. of studies No. of participants

26 Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels

(2016)

1 250

27 Gag function - Test3 - Perry (2001) 1 22

28 DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera

(2018)

1 226

29 DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018) 1 225

30 Gag function - Test4 - Perry (2001) 1 157

31 2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008) 1 100

32 Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen -

Mulheren (2019)

1 48

33 Nursing Screening Tool - Bravata (2009) 1 39

34 Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish ver-

sion (T-BJH) - Eren (2019)

1 0

35 Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011) 1 0

36 TOR-BSST water swallow item - Martino (2014) 1 0

37 Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005) 1 0

38 Index taxonomy - water only 13 2914

39 Index taxonomy - water plus other consistencies 5 412

40 Index taxonomy - other 5 627

41 Outcome - aspiration 11 1827

42 Outcome - dysphagia 13 2126

43 Reference test - Expert Assessment and MASA 12 2491

44 Reference test - FEES 3 330

45 Reference test - VF 6 1132

46 HCP - nurse 14 2785

47 HCP - other 8 1168

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Test 1.  Registered Dietitian (RD) Dysphagia Screening tool - Huhmann (2004)



Test 2.  Bedside aspiration - Combined WST & Oxygen Saturation - Lim (2001)



Test 3.  Gugging Swallowing Screen (GUSS) - Group2 - Trappl (2007)



Test 4.  Toronto Bedside Swallowing Screening Test (TOR-BSST) - Martino (2009)



Test 5.  Standardized Swallowing Assessment tool (SSA) - Test2 - Perry (2001) Test2



Test 6.  Nursing Bedside Dysphagia Screen (NBDS) - Campbell (2016)

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Test 7.  Emergency Department (ED) dysphagia screen - Turner-Lawrence (2009)



Test 8.  Acute Stroke Dysphagia Screening (ASDS) - Aspiration - Edmiaston (2010)



Test 9.  Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration - Edmiaston (2014)



Test 10.  Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) plus water swallow test - Huhn-Matesic (2015)



Test 11.  Standardized Swallowing Assessment tool (SSA) - Test1 - Perry (2001)



Test 12.  Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia - Edmiaston (2014)



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Test 13.  Modified MASA (MMASA) Neurologist 1 - Antonios (2010)



Test 14.  Rapid Aspiration Screening for Suspected Stroke (RAS3) - Daniels (2016)



Test 15.  Clinical examination - Daniels (1997)



Test 16.  Acute Stroke Dysphagia Screening (ASDS) Dysphagia - Edmiaston (2010)



Test 17.  Nurse Dysphagia Screen - Cummings (2015)



Test 18.  Modified MASA (MMASA) Neurologist 2 - Antonios (2010)



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Test 19.  Oxygen saturation ≥ 2% - Test2 for Aspiration - Smith (2000)



Test 20.  Bedside swallow test - WST only - Lim (2001)



Test 21.  Chinese version of the modified SSA original 8 items - Jiang (2019)



Test 22.  Chinese version of the modified SSA reduced 6 items - Jiang (2019)



Test 23.  Stroke Severity using National Institutes of Health Stroke Scale (NIHSS) - Bravata (2009)



Test 24.  Nursing Bedside Swallowing Screen (NBSS) - Ellis (2013)

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Test 25.  2-step Swallowing Provocation Test (SPT) - step 1 - 0.4 mL - Warneke (2008)



Test 26.  Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only - Daniels (2016)



Test 27.  Gag function - Test3 - Perry (2001)



Test 28.  DePaul Hospital Swallow Screener (DHSS) for Aspiration Risk - Behera (2018)



Test 29.  DePaul Hospital Swallow Screener (DHSS) for Dysphagia - Behera (2018)



Test 30.  Gag function - Test4 - Perry (2001)

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Test 31.  2-step swallowing provocation test (SPT) step 2 - 2.0 mL - Warneke (2008)



Test 32.  Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen - Mulheren (2019)



Test 33.  Nursing Screening Tool - Bravata (2009)



Test 34.  Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) – Turkish version (T-BJH) - Eren (2019)



Test 35.  Clinical Predicative Scale of Aspiration (CPSA) - Zhou (2011)



Test 36.  TOR-BSST water swallow item - Martino (2014)

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Test 37.  Clinical swallowing tests - 6 oromotor examinations - Nishiwaki (2005)



Test 38.  Index taxonomy - water only



Test 39.  Index taxonomy - water plus other consistencies



Test 40.  Index taxonomy - other

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Test 41.  Outcome - aspiration



Test 42.  Outcome - dysphagia

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Test 43.  Reference test - Expert Assessment and MASA



Test 44.  Reference test - FEES



Test 45.  Reference test - VF

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Test 46.  HCP - nurse



Test 47.  HCP - other



A D D I T I O N A L  T A B L E S



  Tests (percentage)

(n = 37 tests)

Complete or narrative Complete - 2 × 2 table data extracted 33 (89%)

 Narrative - 2 × 2 table data not available 4 (11%)

Participants

NaMedian (IQR) 100 (50 to 161) Min = 22, max = 300

Table 1.  Description of screening tests

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N with dysphagia/aspira-

tiona

Median (IQR) 38 (17 to 63) Min = 8, max = 106

Mean age Median (IQR) 67.6 (64.75 to 71.4) Min = 58.6, max = 76.8

Sex % male Median (IQR) 54.7 (49 to 65.6) Min = 35, max = 100

Year recruitment started  Min = 1995, max = 2016

UK and Europe 8 (22%)

USA and Canada 22 (59%)

Other 6 (16%)

Country

Not recorded 1 (3%)

Study design

≤ 24 hours 16 (43%)

> 24 hours and < 72 hours 6 (16%)

≥ 72 hours 2 (5%)

Admission to index test

Not recorded 13 (35%)

Index then reference 28 (76%)

Reference then index 1 (3%)

Mixed or not specified 5 (14%)

Order tests applied

Not recorded 3 (8%)

≤ 24 hours 18 (49%)

> 24 hours 10 (27%)

Index/reference time in-

terval

Not recorded 9 (24%)

Yes 21 (57%)Index test training given

Not recorded 16 (43%)

Water only 24 (65%)

Water plus other consistencies 6 (16%)

Index test type

Other 7 (19%)

Nurse 21 (57%)Index test HCP

Other 16 (43%)

Outcome Aspiration 15 (41%)

Table 1.  Description of screening tests(Continued)

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Dysphagia 20 (54%)

NR 2 (5%)

Expert assessment and MASA 20 (54%)

FEES 6 (16%)

Reference test

VF 11 (30%)

Table 1.  Description of screening tests(Continued)

aUsing complete studies only.

FEES: fibreoptic endoscopic evaluation of swallowing.

HCP: healthcare professional.

IQR: interquartile range.

MASA: Mann Assessment of Swallowing Ability.

VF: videofluoroscopy.



Test ID Test name

Antonios 2010a Modified MASA (MMASA) Neurologist 1: Antonios 2010

Antonios 2010b Modified MASA (MMASA) Neurologist 2: Antonios 2010

Behera 2018a DePaul Hospital Swallow Screener (DHSS) Aspiration: Behera 2018

Behera 2018b DePaul Hospital Swallow Screener (DHSS) Dysphagia: Behera 2018

Bravata 2009a Nursing Screening Tool: Bravata 2009

Bravata 2009b Stroke Severity using National Institutes of Health Stroke Scale (NIHSS): Bravata 2009

Campbell 2016 Nursing Bedside Dysphagia Screen (NBDS): Campbell 2016

Cummings 2015 Nurse Dysphagia Screen: Cummings 2015

Daniels 1997 Clinical examination: Daniels 1997

Daniels 2016a Rapid Aspiration Screening for Suspected Stroke (RAS3): Daniels 2016

Daniels 2016b Rapid Aspiration Screening for Suspected Stroke (RAS3) - WST only: Daniels 2016

Edmiaston 2010a Acute Stroke Dysphagia Screening (ASDS) Aspiration: Edmiaston 2010

Edmiaston 2010b Acute Stroke Dysphagia Screening (ASDS) Dysphagia: Edmiaston 2010

Edmiaston 2014a Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Aspiration: Edmiaston 2014

Edmiaston 2014b Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) Dysphagia: Edmiaston 2014

Ellis 2013 Nursing Bedside Swallowing Screen (NBSS): Ellis 2013

Eren 2019 Barnes-Jewish Hospital Stroke Dysphagia Screen – Turkish version (BJH-SDS) or (T-BJH): Eren 2019

Table 2.  Index test reference IDs

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Huhmann 2004 Registered Dietitian (RD) Dysphagia Screening tool: Huhmann 2004

Huhn-Matesic 2015 Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS) followed by simple water swallow test:

Huhn-Matesic 2015

Jiang 2019a Chinese version of the modified SSA – original 8 items: Jiang 2019

Jiang 2019b Chinese version of the modified SSA – reduced 6 items: Jiang 2019

Lim 2001a Bedside aspiration - Combined WST and Oxygen Saturation: Lim 2001

Lim 2001b Bedside swallow test - WST only: Lim 2001

Martino 2009 Toronto Bedside Swallowing Screening Test (TOR-BSST): Martino 2009 Study 1

Martino 2014 TOR-BSST water swallow item: Martino 2014

Mulheren 2019 Johns Hopkins Hospital Brain Rescue Unit Modified 3 oz Swallow Screen: Mulheren 2019

Nishiwaki 2005 Clinical swallowing tests: Nishiwaki 2005

Perry 2001a Gag function - Test3: Perry 2001 Study 1

Perry 2001b Gag function - Test4: Perry 2001 Study 1

Perry 2001c Standardized Swallowing Assessment tool (SSA) - Test1: Perry 2001 Study 1

Perry 2001d Standardized Swallowing Assessment tool (SSA) – Test2: Perry 2001 Study 1

Smith 2000 Oxygen saturation ≥ 2% - Test2 for Aspiration: Smith 2000

Trapl 2007b Gugging Swallowing Screen (GUSS) - Group2: Trapl 2007

Turner-Lawrence 2009 Emergency Department (ED) dysphagia screen: Turner-Lawrence 2009

Warnecke 2008a 2-step swallowing provocation test (SPT) - step 1 - 0.4 mL: Warnecke 2008

Warnecke 2008b 2-step swallowing provocation test (SPT) - step 2 - 2.0 mL: Warnecke 2008

Zhou 2011 Clinical predicative scale of aspiration (CPSA): Zhou 2011

Table 2.  Index test reference IDs(Continued)



A P P E N D I C E S

Appendix 1. MEDLINE search strategy

1. cerebrovascular disorders/ or basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp

cerebral small vessel diseases/ or exp intracranial arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial

hemorrhages/ or stroke/ or exp brain infarction/ or stroke, lacunar/ or vasospasm, intracranial/ or vertebral artery dissection/

2. (stroke$ or poststroke or apoplex$ or cerebral vasc$ or brain vasc$ or cerebrovasc$ or cva$ or SAH).tw.

3. ((brain or cerebr$ or cerebell$ or vertebrobasil$ or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or middle

cerebral artery or MCA$ or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) adj5 (isch?

emi$ or infarct$ or thrombo$ or emboli$ or occlus$ or hypoxi$)).tw.

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4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli$ or putaminal or putamen or posterior fossa or hemispher$ or subarachnoid) adj5 (h?emorrhag$ or h?

ematoma$ or bleed$)).tw.

5. hemiplegia/ or exp paresis/ or exp Gait Disorders, Neurologic/

6. (hemipleg$ or hemipar$ or paresis or paraparesis or paretic).tw.

7. or/1-6

8. Deglutition/

9. exp Deglutition Disorders/

10. ((swallow$ or deglutit$ or dysphag$) adj3 (disturbance$ or disorder$ or diicult$ or dysfunction$ or impair$ or condition$ or abnormal

$ or damage$ or injur$)).tw.

11. ((swallow$ or deglutit$ or dysphag$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or

diagnos$ or detect$ or hazard or risk or test)).tw.

12. exp Respiratory Aspiration/ or exp Pneumonia, Aspiration/

13. ((inhal$ or aspirat$ or ingest$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or diagnos

$ or detect$ or hazard or risk or test)).tw.

14. Pharynx/ or pharyngeal muscles/ or esophageal sphincter, upper/ or exp Esophagus/

15. ((throat or oesophag$ or esophag$ or pharyn$ or oropharyn$) adj3 (disturbance$ or disorder$ or diicult$ or dysfunction$ or impair

$ or condition$ or abnormal$ or damage$ or injur$)).tw.

16. exp Fluoroscopy/ or bronchoscopy/ or laryngoscopy/ or endoscopy/ or manometry/

17. Fiber Optic Technology/

18. (fluoroscop$ or videofluroscop$ or fluorescence radiation or fluorescent scan$ or fluorophotograph$ or photofluoroscop

$ or radiofluoroscop$ or roentgenfluoroscop$ or bronchoscop$ or bronchial endoscop$ or laryngotracheobronchoscop$ or

tracheobronchoscop$).tw.

19. or/8-18

20. 7 and 19

Appendix 2. Cochrane Central Register of Controlled Trials (CENTRAL)

June 2017 search – was applied to CENTRAL and HTA

December 2019 search –applied separately to CENTRAL and HTA. HTA was only available until March 2018.

ID Search Hits

#1 MeSH descriptor: [Cerebrovascular Disorders] this term only

#2 MeSH descriptor: [Basal Ganglia Cerebrovascular Disease] this term only

#3 MeSH descriptor: [Brain Ischemia] explode all trees

#4 MeSH descriptor: [Carotid Artery Diseases] explode all trees

#5 MeSH descriptor: [Cerebral Small Vessel Diseases] explode all trees

#6 MeSH descriptor: [Intracranial Arterial Diseases] explode all trees

#7 MeSH descriptor: [Intracranial Embolism and Thrombosis] explode all trees

#8 MeSH descriptor: [Intracranial Hemorrhages] explode all trees

#9 MeSH descriptor: [Stroke] explode all trees

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#10 MeSH descriptor: [Vasospasm, Intracranial] this term only

#11 MeSH descriptor: [Vertebral Artery Dissection] this term only

#12 (stroke* or poststroke or apoplex* or cerebral vasc* or brain vasc* or cerebrovasc* or cva* or SAH):ti,ab,kw (Word variations have been

searched)

#13 ((brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or middle

cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) near/5 (isch?

emi* or infarct* or thrombo* or emboli* or occlus* or hypoxi*)):ti,ab,kw (Word variations have been searched)

#14 ((brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid) near/5 (h?emorrhag* or h?

ematoma* or bleed*)):ti,ab,kw (Word variations have been searched)

#15 MeSH descriptor: [Hemiplegia] this term only

#16 MeSH descriptor: [Paresis] explode all trees

#17 MeSH descriptor: [Gait Disorders, Neurologic] explode all trees

#18 (hemipleg* or hemipar* or paresis or paraparesis or paretic):ti,ab,kw (Word variations have been searched)

#19 {or #1-#18}

#20 MeSH descriptor: [Deglutition] this term only

#21 MeSH descriptor: [Deglutition Disorders] explode all trees

#22 ((swallow* or deglutit* or dysphag*) near/3 (disturbance* or disorder* or diicult* or dysfunction* or impair* or condition* or abnormal*

or damage* or injur*)):ti,ab,kw (Word variations have been searched)

#23 ((swallow* or deglutit* or dysphag*) near/3 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or

diagnos* or detect* or hazard or risk or test)):ti,ab,kw (Word variations have been searched)

#24 MeSH descriptor: [Respiratory Aspiration] explode all trees

#25 MeSH descriptor: [Pneumonia, Aspiration] explode all trees

#26 ((inhal* or aspirat* or ingest*) near/3 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*

or detect* or hazard or risk or test)):ti,ab,kw (Word variations have been searched)

#27 MeSH descriptor: [Pharynx] this term only

#28 MeSH descriptor: [Pharyngeal Muscles] this term only

#29 MeSH descriptor: [Esophageal Sphincter, Upper] this term only

#30 MeSH descriptor: [Esophagus] explode all trees

#31 ((throat or oesophag* or esophag* or pharyn* or oropharyn*) near/3 (disturbance* or disorder* or diicult* or dysfunction* or impair*

or condition* or abnormal* or damage* or injur*)):ti,ab,kw (Word variations have been searched)

#32 MeSH descriptor: [Fluoroscopy] explode all trees

#33 MeSH descriptor: [Bronchoscopy] this term only

#34 MeSH descriptor: [Laryngoscopy] this term only

#35 MeSH descriptor: [Endoscopy] this term only

#36 MeSH descriptor: [Manometry] this term only

#37 MeSH descriptor: [Fiber Optic Technology] this term only

#38 (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop* or

tracheobronchoscop*):ti,ab,kw (Word variations have been searched)

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#39 {or #20-#38}

#40 #19 and #39

Appendix 3. Embase search strategy

1. cerebrovascular disease/ or brain disease/ or exp basal ganglion hemorrhage/ or exp brain hemangioma/ or exp brain hematoma/ or

exp brain hemorrhage/ or exp brain infarction/ or exp brain ischemia/ or exp carotid artery disease/ or exp cerebral artery disease/ or exp

cerebrovascular accident/ or exp cerebrovascular malformation/ or exp intracranial aneurysm/ or exp occlusive cerebrovascular disease/

or exp vertebrobasilar insuiciency/

2. (stroke$ or poststroke or apoplex$ or cerebral vasc$ or brain vasc$ or cerebrovasc$ or cva$ or SAH).tw.

3. ((brain or cerebr$ or cerebell$ or vertebrobasil$ or hemispher$ or intracran$ or intracerebral or infratentorial or supratentorial or middle

cerebral artery or MCA$ or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) adj5 (isch?

emi$ or infarct$ or thrombo$ or emboli$ or occlus$ or hypoxi$)).tw.

4. ((brain$ or cerebr$ or cerebell$ or intracerebral or intracran$ or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli$ or putaminal or putamen or posterior fossa or hemispher$ or subarachnoid) adj5 (h?emorrhag$ or h?

ematoma$ or bleed$)).tw.

5. exp hemiplegia/ or exp paresis/ or neurologic gait disorder/

6. (hemipleg$ or hemipar$ or paresis or paraparesis or paretic).tw.

7. or/1-6

8. dysphagia/

9. swallowing/

10. ((swallow$ or deglutit$ or dysphag$) adj3 (disturbance$ or disorder$ or diicult$ or dysfunction$ or impair$ or condition$ or abnormal

$ or damage$ or injur$)).tw.

11. ((swallow$ or deglutit$ or dysphag$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or

diagnos$ or detect$ or hazard or risk or test)).tw.

12. aspiration pneumonia/ or aspiration/

13. acid aspiration/

14. ((inhal$ or aspirat$ or ingest$) adj3 (scale$ or screen$ or checklist$ or assess$ or exam$ or identif$ or recogni$ or evaluat$ or diagnos

$ or detect$ or hazard or risk or test)).tw.

15. exp pharynx/

16. exp esophagus/ or esophagus muscle/ or upper esophagus sphincter/

17. ((throat or oesophag$ or esophag$ or pharyn$ or oropharyn$) adj3 (disturbance$ or disorder$ or diicult$ or dysfunction$ or impair

$ or condition$ or abnormal$ or damage$ or injur$)).tw.

18. fluoroscopy/ or fluoroscopy system/

19. exp bronchoscopy/ or bronchus examination/

20. exp laryngoscope/ or exp laryngoscopy/

21. endoscopy/ or fiberscope endoscopy/ or videoendoscopy/

22. manometry/

23. (fluoroscop$ or videofluroscop$ or fluorescence radiation or fluorescent scan$ or fluorophotograph$ or photofluoroscop

$ or radiofluoroscop$ or roentgenfluoroscop$ or bronchoscop$ or bronchial endoscop$ or laryngotracheobronchoscop$ or

tracheobronchoscop$).tw.

24. or/8-23

25. 7 and 24

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Appendix 4. CINAHL search strategy

S1 (MH "Cerebrovascular Disorders") OR (MH "Basal Ganglia Cerebrovascular Disease+") OR (MH "Carotid Artery Diseases+") OR (MH

"Cerebral Ischemia+") OR (MH "Cerebral Vasospasm") OR (MH "Intracranial Arterial Diseases+") OR ( (MH "Intracranial Embolism and

Thrombosis") ) OR (MH "Intracranial Hemorrhage+") OR (MH "Stroke") OR (MH "Vertebral Artery Dissections") OR (MH "Stroke Patients")

OR (MH "Stroke Units")

S2 TI ( stroke or poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH ) or AB ( stroke or

poststroke or post-stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH)

S3 TI ( brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or

middle cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) N5

TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus*)

S4 AB ( brain or cerebr* or cerebell* or vertebrobasil* or hemispher* or intracran* or intracerebral or infratentorial or supratentorial or

middle cerebral artery or MCA* or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) N5

AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus*)

S5 TI ( brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid ) N5 TI ( haemorrhage* or

hemorrhage* or haematoma* or hematoma* or bleed* )

S6 AB ( brain* or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial

or supratentorial or basal gangli* or putaminal or putamen or posterior fossa or hemispher* or subarachnoid ) N5 AB ( haemorrhage* or

hemorrhage* or haematoma* or hematoma* or bleed* )

S7 (MH "Hemiplegia") or (MH "Gait Disorders, Neurologic+")

S8 TI ( (hemipleg* or hemipar* or paresis or paretic) ) OR AB ( (hemipleg* or hemipar* or paresis or paretic) )

S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8

S10 (MH "Deglutition") OR (MH "Gagging")

S11 (MH "Deglutition Disorders")

S12 TI ( (swallow* or deglutit* or dysphag*) N5 (disturbance* or disorder* or diicult* or dysfunction* or impair* or condition* or abnormal*

or damage* or injur*) ) OR AB ( (swallow* or deglutit* or dysphag*) N5 (disturbance* or disorder* or diicult* or dysfunction* or impair*

or condition* or abnormal* or damage* or injur*) )

S13 TI ((swallow* or deglutit* or dysphag*) N5 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or

diagnos* or detect* or hazard or risk or test)) OR AB ((swallow* or deglutit* or dysphag*) N5 (scale* or screen* or checklist* or assess* or

exam* or identif* or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test))

S14 (MH "Aspiration")

S15 (MH "Pneumonia, Aspiration")

S16 (MH "Risk for Aspiration (NANDA)")

S17 TI ((inhal* or aspirat* or ingest*) N5 (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*

or detect* or hazard or risk or test)) OR AB ((inhal* or aspirat* or ingest*) N5 (scale* or screen* or checklist* or assess* or exam* or identif*

or recogni* or evaluat* or diagnos* or detect* or hazard or risk or test))

S18 (MH "Pharynx+")

S19 (MH "Esophagus")

S20 TI ((throat or oesophag* or esophag* or pharyn* or oropharyn*) N5 (disturbance* or disorder* or diicult* or dysfunction* or impair*

or condition* or abnormal* or damage* or injur*)) OR AB ((throat or oesophag* or esophag* or pharyn* or oropharyn*) N5 (disturbance* or

disorder* or diicult* or dysfunction* or impair* or condition* or abnormal* or damage* or injur*))

S21 (MH "Fiber Optics")

S22 TI ( (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop* or

tracheobronchoscop*) ) OR AB ( (fluoroscop* or videofluroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or

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photofluoroscop* or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop*

or tracheobronchoscop*) )

S23 S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22

S24 S9 AND S23

Appendix 5. HTA search strategy

1. cerebrovascular disorders/ or exp brain ischemia/ or exp carotid artery diseases/ or exp cerebral small vessel diseases/ or exp intracranial

arterial diseases/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/ or

vasospasm, intracranial/ or vertebral artery dissection/

2. (stroke or strokes or poststroke or cerebral vasc* or brain vasc$ or cerebrovasc* or cva or SAH) any field

3. ((brain or cerebr* or cerebell* or vertebrobasil* or hemisphere* or intracran* or intracerebral or infratentorial or supratentorial or middle

cerebral artery or MCA or anterior circulation or posterior circulation or basilar artery or vertebral artery or space-occupying) and (ischemi*

or ischaemi* or infarct* or thrombo* or emboli* or occlus* or hypoxi*)) any field

4. ((brain or cerebr* or cerebell* or intracerebral or intracran* or parenchymal or intraparenchymal or intraventricular or infratentorial or

supratentorial or posterior fossa or hemisphere* or subarachnoid) and (haemorrhag* or hemorrhag* or hematoma* or haematoma* or

bleed*)) any field

5. exp paresis/ or exp Gait Disorders, Neurologic/

6. (hemipleg* or paresis or paraparesis or paretic) any field

7. or/1-6

8. Deglutition/

9. exp Deglutition Disorders/

10. ((swallow* or deglutit* or dysphag*) and (disturbance* or disorder* or diicult* or dysfunction* or impair* or condition* or abnormal*

or damage* or injur*)) any field

11. ((swallow* or deglutit* or dysphag*) and (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or

diagnos* or detect* or hazard or risk or test)) any field

12. exp Pneumonia, Aspiration/

13. ((inhal* or aspirat* or ingest*) and (scale* or screen* or checklist* or assess* or exam* or identif* or recogni* or evaluat* or diagnos*

or detect* or hazard or risk or test)) any field

14. Pharynx/ or pharyngeal muscles/ or exp Esophagus/

15. ((throat or oesophag* or esophag* or pharyn* or oropharynx*) and (disturbance* or disorder* or diicult* or dysfunction* or impair*

or condition* or abnormal* or damage* or injur*)) any field

16. exp Fluoroscopy/ or bronchoscopy/ or laryngoscopy/ or endoscopy/ or manometry/

17. (fluoroscop* or videofluoroscop* or fluorescence radiation or fluorescent scan* or fluorophotograph* or photofluoroscop*

or radiofluoroscop* or roentgenfluoroscop* or bronchoscop* or bronchial endoscop* or laryngotracheobronchoscop* or

tracheobronchoscop*) any field

18. or/8-17

29. 7 and 18

Appendix 6. List of targeted grey literature sources (CADTH, 2018)

•Health Quality Council of Alberta (HQCA) http://hqca.ca/studies-and-reviews/completed-reviews/

•Institut national d’excellence en santé et en services sociaux (INESSS) [formerly AETMIS] http://www.inesss.qc.ca/en/publications/

publications.html

•Manitoba Centre for Health Policy (MCHP) http://mchp-appserv.cpe.umanitoba.ca/deliverablesList.html

•NLCAHR : Newfoundland and Labrador Centre for Applied Health Research. Contextualized Health Research Synthesis Program (CHRSP)

http://www.nlcahr.mun.ca/CHRSP/CompletedCHRSP.php

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•Ottawa Hospital Research Institute (OHRI) http://www.ohri.ca/ksgroup/publications.asp

•Therapeutics Initiative. Therapeutics Letter http://www.ti.ubc.ca/TherapeuticsLetter

•University of British Columbia. Centre for Health Services and Policy Research http://chspr.ubc.ca/publications/

•World Health Organization Regional Oice for Europe. Health Evidence Network (WHO HEN) http://www.euro.who.int/en/data-and-

evidence/evidence-informed-policy-making/publications/by-keyword

•Australian Government. Department of Health and Ageing. Australia and New Zealand Horizon Scanning Network (ANZHSN). http://

www.horizonscanning.gov.au/internet/horizon/publishing.nsf/Content/technologies-assessed-lp-2

•Australian Government Department of Health and Ageing. Medical Services Advisory Committee (MSAC). http://www.msac.gov.au/

internet/msac/publishing.nsf/Content/completed-assessments

•Joanna Briggs Institute (JBI). The Joanna Briggs Institute EBP Database http://connect.jbiconnectplus.org/Search.aspx

•Monash Health. Centre for Clinical Eectiveness (CCE). Centre for Clinical Eectiveness – Publications http://monashhealth.org/health-

professionals/cce/cce-publications/

•Queensland Government (Australia). Health Technology Reference Group. Health Technologies Evaluated-Reports and Briefs (COAG

Health Council). https://www.coaghealthcouncil.gov.au/AHMAC/Health-Technology-Reference-Group/Reports-and-Briefs

•Kenniscentrum voor de Gezondheidszorg / Le Centre d'expertise des soins de santé. Belgian Health Care Knowledge Centre (KCE)

https://kce.fgov.be/en/all-reports

•Sundhedsstyrelsen. Danish Health and Medicines Authority (DHMA). http://sundhedsstyrelsen.dk/en/publications

•Haute Autorité de santé/ French National Authority for Health (HAS). Haute Autorité de santé http://www.has-sante.fr/portail/jcms/

c_946986/en/english-toutes-nos-publications-ligne-principale?portal=r_1457306

•Health Service Executive. Irish Health Repository (Lenus) http://www.lenus.ie/hse/

•De Gezondheidsraad (GR). Health Council of the Netherlands http://www.gezondheidsraad.nl/en/publications

•Zorginstituut Nederland. National Health Care Institute Netherlands https://english.zorginstituutnederland.nl/publications

•Folkehelseinstituttet. Norwegian Institute of Public Health. Publications https://www.fhi.no/en/publ/

•Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS). Agency for Health Quality and Assessment of Catalonia http://

aquas.gencat.cat/ca/publicacions/

•Sahlgrenska Universitetssjukhuset. Sahlgrenska University Hospital. Regional activity-based HTA. https://www.sahlgrenska.se/

forskning/htacentrum/

•Healthcare Improvement Scotland. http://www.healthcareimprovementscotland.org/

•NHS National Institute for Health and Care Excellence (NICE). http://www.nice.org.uk/

•UK Department of Health (NHS). International Resource for Infection Control (INRIC) https://www.nric.org.uk/resources

•Agency for Healthcare Research and Quality (AHRQ). Technology Assessments https://www.ahrq.gov/research/findings/ta/index.html

•Institute for Clinical and Economic Review (ICER). https://icer-review.org/materials/

Appendix 7. QUADAS-2 tool: risk of bias and applicability judgements



Domain 1. Patient selection

1. Risk of bias 

Describe methods of patient selection:

· Was a consecutive or random sample of patients enrolled? Yes/No/Unclear

•Was a case-control design avoided? Yes/No/Unclear

•Did the study avoid inappropriate exclusions? Yes/No/Unclear

· Could the selection of patients have introduced bias? RISK: LOW/HIGH/UNCLEAR

1. Concerns regarding applicability 

Describe included patients (prior testing, presentation, intended use of index test and setting):



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Is there concern that the included patients do not match the review question? CONCERN: LOW/HIGH/UN-

CLEAR

Domain 2. Index test(s) (if more than 1 index test was used, please complete for each test)

1. Risk of bias 

Describe the index test and how it was conducted and interpreted:

•Were the index test results interpreted without knowledge of results of the reference stan-

dard?

Yes/No/Unclear

•If a threshold was used, was it prespecified? Yes/No/Unclear

· Could conduct or interpretation of the index test have introduced bias? RISK: LOW/HIGH/UNCLEAR

1. Concerns regarding applicability 

Is there concern that the index test, its conduct, or its interpretation differ from the review

question?

CONCERN: LOW/HIGH/UN-

CLEAR

Domain 3. Reference standard

1. Risk of bias 

Describe the reference standard and how it was conducted and interpreted:

•Is the reference standard likely to correctly classify the target condition? Yes/No/Unclear

•Were the reference standard results interpreted without knowledge of results of the index

test?

Yes/No/Unclear

· Could the reference standard, its conduct, or its interpretation have introduced bias? RISK: LOW/HIGH/UNCLEAR

1. Concerns regarding applicability 

Is there concern that the target condition as defined by the reference standard does not

match the review question?

CONCERN: LOW/HIGH/UN-

CLEAR

Domain 4. Flow and timing

1. Risk of bias 

Describe any patients who did not receive the index test(s) and/or reference standard or who were excluded from the 2 ×2 ta-

ble (refer to flow diagram):

Describe the time interval and any interventions between index test(s) and reference standard:

•Was there an appropriate interval between index test(s) and reference standard? Yes/No/Unclear

•Did all patients receive a reference standard? Yes/No/Unclear

•Did patients receive the same reference standard? Yes/No/Unclear

•Were all patients included in the analysis? Yes/No/Unclear

· Could the patient flow have introduced bias? RISK: LOW/HIGH/UNCLEAR

(Continued)

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

Appendix 8. Description of screening tests

Bedside Aspiration Test ( Lim 2001 a)

Stage 1: the Water Swallow Test assessed patient’s ability to swallow 50 mL of water in 10-mL aliquots. The patient is seated upright and

is asked to drink all of the 50 mL. Patients were deemed to be clinically aspirating if they coughed or choked during the water drinking

test or had a change in their voice quality following the swallow. Patients were monitored for these signs of possible aspiration for up to

5 minutes aer swallowing.

Stage 2: aer a rest period of 10 minutes, the Oxygen Saturation Test was conducted. The finger probe of a Novametrix Oxypleth pulse

oximeter (model 520A) was placed on the index finger of the unaected hand of the patient, with the patient in an upright position. Aer

equilibrating for 5 minutes, a baseline oxygen saturation reading was taken. A drop > 2% in arterial oxygen saturation was considered

clinically significant (Collins and Bakheit 1997). Maximum and minimum oxygen saturation readings during and for up to 2 minutes aer

swallowing 10 mL of water were noted 3 times, and highest and lowest readings were taken. If oxygen saturation fell by 5% or more,

the test was stopped immediately to stop an additional decline in arterial blood oxygenation levels, especially in patients who may have

compromised pulmonary function. Aspiration was deemed present if overt signs of aspiration and/or oxygen desaturation of 2% or more

was noted.

Gugging Swallowing Screen ( Trapl 2007 b)

The Bedside Gugging Swallow Screen (GUSS) consists of two parts. Part 1, the preliminary assessment, involved a simple saliva swallow

test. Patients who were unable to produce enough saliva because of dry mouth were given saliva spray as a substitute. Vigilance, voluntary

cough, throat clearing, and saliva swallowing were assessed. Part 2 consisted of 3 sequentially performed subtests, starting with semisolid

(thickened distilled water), then liquid (increasing amounts of 3, 5, 10, 20, and 50 mL), and finally solid textures (5 tests with dry bread).

Ten seconds is the time limit for a small solid bolus, including the oral preparatory phase. The test was stopped if 1 of the 4 aspiration signs

(deglutition, cough, drooling, and voice change) was positive. Patients must successfully complete all repetitions in the subtest to achieve

the full score of 5 points. If a subtest results in < 5 points, the examination is stopped and a special oral diet and/or further investigation by

videofluoroscopy or fibreoptic endoscopy is recommended. Diet recommendations are then oered, aligned to the functional oral intake

scale, and are given according to points reached in the GUSS.

The Toronto Bedside Swallow Screening Test ( Martino 2009 Study 1 )

The Toronto Bedside Swallowing Screening Test (TOR-BSST) included the following tests: the Kidd 50 mL water swallow test, pharyngeal

sensation, tongue movement, and general dysphonia split into 2 items - 'voice before' and 'voice aer'. A pass/fail response was assigned

to each item, so that failure on any item constitutes a positive screen result and therefore increased risk for dysphagia. Administration

continues only until the first TOR-BSST item is failed.

W H A T ' S  N E W



Date Event Description

13 July 2021 Amended Paper submitted with amendments in response to reviewers'

comments



H I S T O R Y

Protocol first published: Issue 6, 2017



Date Event Description

26 February 2021 Amended Paper submitted with amendments in response to reviewers'

comments

30 September 2020 Amended Paper submitted

30 January 2017 Amended Protocol amended in response to reviewers' comments

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

C O N T R I B U T I O N S  O F  A U T H O R S

EB, JB, and LH draed the review and developed the background section with support from CW. PD, AC, MH, and CW, who also provided

advice regarding the methodological perspective and content. EB, JB, LH, PD, LL, ML, HR, EM, AA, and CW provided support for data

collection and analysis, and MH provided statistical expertise. All review authors commented on all sections of the review and reviewed

the final version prior to submission.

D E C L A R A T I O N S  O F  I N T E R E S T

Elizabeth Boaden: none known.

Jane Burnell: none known.

Lucy Hives: none known.

Paola Dey: "my institution has received funding for consultancies and grants in aid from NHS, government and research charities. I have

also been in receipt of a travel bursary from the organisers of the United European Gastroenterology Week in Berlin in 2006"

Andrew Clegg: none known.

Mary W Lyons: none known.

C Elizabeth Lightbody: none known.

Margaret A Hurley: none known.

Hazel Roddam: none known.

Elizabeth McInnes: none known.

Anne Alexandrov: none known.

Caroline L Watkins: none known.

S O U R C E S  O F  S U P P O R T

Internal sources

•No sources of support provided

External sources

•No sources of support provided

D I F F E R E N C E S  B E T W E E N  P R O T O C O L  A N D  R E V I E W

We did not perform meta-analyses, as the number of studies for each individual index test was insuicient, that is, did not include at

least four per group. We have presented only descriptive analyses grouped by general categories. Hence we performed no analysis of the

influence of sources of heterogeneity, no subgroup analysis, and no sensitivity analysis. None of the included studies used scintigraphy

as the reference test. We included studies in which the index test was carried out by any healthcare professionals with the exception of

speech and language therapists (SLTs).

Screening for aspiration risk associated with dysphagia in acute stroke (Review)

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Mortality and Pulmonary Complications of Post-stroke Dysphagia: A Casuistic Review of an Acute Stroke Unit

Article

Full-text available

Dec 2024

Introduction: Dysphagia is a common post-stroke neurological disorder. Early screening for dysphagia can identify patients at risk of aspiration, thereby reducing the occurrence of pulmonary complications, morbidity, and mortality in this population. Objectives: This study aims to evaluate the impact of an intervention in a stroke unit, following a retrospective study carried out in the same unit in 2020, which investigated the association between dysphagia and acute cerebrovascular disease and analyzed the prevalence of readmissions due to respiratory tract infections (RTI) and mortality. An assessment of the factors related to a higher risk of developing post-stroke dysphagia was also performed. Material and methods: A retrospective observational study analyzed 210 clinical records of patients with acute cerebrovascular disease, including clinical history, neurological examination, imaging, and Gugging Swallowing Screen in the initial 48 hours. Patient follow-up for three months through medical records was used to evaluate RTI and mortality. Results: Among the 210 clinical records examined, 209 (99.5%) underwent dysphagia assessment, contrasting with the previously reported casuistic from this unit (40.8%). The prevalence of dysphagia was also higher (50.7% vs. 32.4%). Over a three-month follow-up, RTI occurred in 19% of all patients, in 35.8% of all dysphagic patients, and in 67.7% (p<0.001) of those with severe dysphagia. The overall three-month mortality rate was 9.0% and 12.3% in dysphagic patients, particularly in patients with severe dysphagia (29.0%; p<0.001). Compared to the previous report, this study found a decrease of 1.4% in all-cause mortality (9.0% vs. 10.4%), 11.9% in all-cause mortality in dysphagic patients (12.3% vs. 24.2%), and 46% in all-cause mortality in patients with severe dysphagia (29.0% vs. 75.0%). A higher risk of dysphagia was significantly associated with older age (p<0.001), female gender (p<0.006), severe stroke (p<0.001), hemorrhagic stroke (p=0.005), strokes involving the carotid territory (p=0.040), dysarthria (p=0.004), aphasia (p<0.001), and type of aphasia, particularly global and Broca's aphasia (p=0.022). Conclusions: The recent rates of all-cause mortality at the three-month follow-up, especially in the severe dysphagia group, indicate an overall improvement in the quality of patient care in the stroke unit intervened with regard to dysphagia, while the higher prevalence of RTI post-stroke at three months may not only reflect the larger number of patients screened for dysphagia but also aging, multimorbidity, and the increasing incidence of stroke on the Portuguese population. The type of cerebrovascular disease, vascular territory, age, gender, National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, dysarthria, aphasia, and type of aphasia were significant associated factors to post-stroke dysphagia. The intervention of a multi-professional team with the implementation of a protocol for early dysphagia screening is crucial to optimizing the outcomes of patients with post-stroke dysphagia.

Efficacy of Game-Based EMG-Biofeedback Therapy in Post-Stroke Dysphagia: A Randomized Controlled Trial

Article

Full-text available

Mar 2025
Dysphagia

The aim of the present study was to investigate the effects of game-based electromyography (EMG)-biofeedback therapy on swallowing functions and quality of life in patients with post-stroke dysphagia. The prospective, double-blind, randomized controlled trial included 33 patients with post-stroke dysphagia. The study group performed the Mendelsohn maneuver and effortful swallow using game-based EMG-biofeedback, while the control group performed the Mendelsohn maneuver and effortful swallow using only verbal feedback for 30 min in 15 sessions in total. Before and during the trial, patients were evaluated using clinical swallowing assessments such as the Functional Oral Intake Scale (FOIS), Penetration–Aspiration Scale (PAS), Dysphagia Outcome and Severity Scale (DOSS), and Dysphagia Handicap Index (DHI). Statistically significant improvement was found in FOIS scores (p = 0.038), PAS-Liquid scores (p = 0.026), and DOSS scores (p = 0.003) in the study group, while there was no statistically significant change in the control group. While PAS-Semisolid scores improved in both groups (study group, p = 0.002; control group, p = 0.023), post-treatment scores were statistically significantly higher in the study group than in the control group (p = 0.031). Although statistically significant improvement was found in DHI total, physical, emotional, and functional scores in both groups at the end of treatment (p < 0.05 for all), the post-treatment DHI scores were statistically significantly higher in the study group compared to those in the control group (p < 0.05 for all). The addition of game-based EMG-biofeedback to conventional treatment improved clinical and radiological assessments demonstrated by FOIS, PAS-Liquid, and DOSS scores and resulted in a statistically significant improvement in PAS-Semisolid and DHI scores. In conclusion, we believe that the inclusion of game-based EMG-biofeedback therapy in swallowing rehabilitation programs may have a positive impact on treatment outcomes.

Effectiveness of intermittent theta burst stimulation (iTBS) for managing post-stroke dysphagia: systematic review and meta-analysis

Article

Dec 2024
TOP STROKE REHABIL

Background: Post-Stroke Dysphagia (PSD) is a common complication that significantly affects the quality of life and health outcomes of stroke survivors. Traditional treatments often have limitations, necessitating the exploration of new therapeutic approaches. This systematic review and meta-analysis aimed to evaluate the efficacy of intermittent Theta Burst Stimulation (iTBS) as an innovative treatment for PSD. Methods: Following the PRISMA guidelines, a comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library up to July 2024. Studies included were randomized controlled trials (RCTs) involving stroke patients with confirmed dysphagia, comparing iTBS to control treatments. Data extraction and quality assessment were performed independently by two reviewers using the Cochrane RoB 2 tool. Primary outcomes were changes in the Penetration-Aspiration Scale (PAS) and Swallowing Severity Scale (SSA). Meta-analyses were conducted using Review Manager (RevMan) 5.4. Results: Four RCTs with a total of 199 participants were included. iTBS significantly improved SSA (MD = -3.26, 95% CI [-4.66, -1.86], p < 0.001) and PAS (MD = -1.67, 95% CI [-2.49, -0.86], p < 0.001) immediately after treatment compared to sham stimulation. No significant adverse events were reported. Conclusion: iTBS appears to have a positive immediate effect on improving swallowing function and reducing aspiration risk in PSD patients compared to sham stimulation. However, these effects may not persist in the long term, and further large-scale RCTs are needed to confirm these findings and establish standardized treatment protocols.

A Machine-Learning Model Based on Clinical Features for the Prediction of Severe Dysphagia After Ischemic Stroke

Article

Full-text available

Nov 2024

Background This study aimed to construct machine-learning models for prediction of severe dysphagia after ischemic stroke based on clinical features and identify significant clinical predictors. Methods Patients hospitalized with dysphagia after ischemic stroke in Affiliated Hospital of Jiangnan University were retrospectively analyzed and randomly divided into training and validation sets at a ratio of 7:3. Additional patients from Huai’an Hospital were selected as test set. 19 relevant clinical characteristics were collected. According to the water swallowing test (WST), patients were divided into severe dysphagia group and non-severe dysphagia group. K-nearest neighbor (KNN), decision tree (DT), random forest (RF), support vector machine (SVM), light gradient boosting machine (LGBM), and extreme gradient boosting (XGBoost) were applied to predict severe dysphagia. Receiver operating characteristic (ROC) curves were plotted, the area under the ROC (AUC) was calculated to assess predictive power, and DeLong’s test was used to compare the AUCs among six models. Finally, an optimal model was obtained, and significant clinical predictors of severe dysphagia after stroke were screened. Results A total of 724 patients were enrolled, 422 in training set, 182 in validation set and 120 in test set, respectively, with no statistically differences in baseline information (P>0.05). In the training set, the AUCs of KNN, DT, RF, SVM and XGBoost were higher than that of LGBM (P<0.05). In the validation and test sets, the AUCs of XGBoost were also higher. The performance metrics of XGBoost were better in terms of accuracy, precision, recall, and F1-score. Therefore, XGBoost was the best model, with good clinical practicality. Furthermore, the top five features based on XGBoost were NIHSS score, BI, BMI, age and time since stroke onset. Conclusion Among all clinical feature-based machine-learning models for the prediction of severe dysphagia after ischemic stroke, XGBoost had the best predictive value.

Research Progress in Nursing Assessment and Screening of Swallowing Disorders in Stroke Patients

Article

Jan 2025

小玲胡

The Relationship between Early Dysphagia Screening and Incidence of Pneumonia among Acute Stroke Patients

Article

Full-text available

Dec 2024

Background: Post-stroke dysphagia is a common complication of acute stroke, which could increase the risk of mortality and aspiration pneumonia. Aim: This study aimed to assess the relationship between early dysphagia screening and the incidence of pneumonia among acute stroke patients. Research design: A correlational descriptive design was utilized in this study. Setting: The study was conducted at the stroke and neurology intensive care units at As-Salam International Hospital. Subject: a purposive sample of 87 adult patients newly admitted with a diagnosis of acute stroke was included in the study. Tools: Three tools were used in this study, Tool I: patients' structured interview questionnaire. It consisted of patients' demographic data and current and past history. Tool II gagging swallowing screen. Tool III: Assessment of stroke-associated pneumonia. Results: The study findings revealed that more than one third of the studied patients had dysphagia, and the minority of the studied patients had pneumonia with a statistically significant relation between the incidence of pneumonia and the incidence of dysphagia. As well as there was a positive correlation between the incidence of dysphagia and the incidence of pneumonia. Conclusion: There was a statistically significant relation between early dysphagia screening and the incidence of pneumonia among acute stroke patients. Recommendation: Early dysphagia screening practices should be applied to acute stroke patients before oral intake and within 24 hours of admission to reduce the incidence of pneumonia.

Schluckbeschwerden

Chapter

Jan 2025

Karen Krüger

Effect of artificial intelligence-based video-game system on dysphagia in patients with stroke: A randomized controlled trial

Article

Dec 2024
CLIN NUTR

Efficacy of enhanced dysphagia assessment and dietary intervention in post-stroke dysphagia patients: a randomized controlled study

Article

Full-text available

Dec 2024
Eur Arch Oto Rhino Laryngol

Objective This study evaluated the effectiveness of an enhanced dysphagia assessment method combined with dietary interventions for patients experiencing dysphagia post-stroke. Methods A prospective randomized controlled trial was conducted with 98 hospitalized post-stroke patients suffering from dysphagia. Participants were randomly assigned into two groups: the study group (receiving enhanced dysphagia assessment and dietary interventions) and the control group (receiving standard nursing care), using a computer-generated randomization list. Swallowing function was assessed using the Mann Assessment of Swallowing Ability (mMASA), Dysphagia Severity Scale (DSS), and Wada’s water swallowing test. Additionally, quality of life and nutritional status were evaluated for both groups, before and after the intervention. Results Post-intervention, the study group exhibited significantly better scores on mMASA and Wada’s water swallowing test, and lower DSS scores compared to the control group (all P < 0.05). Initially, no significant differences were observed between the groups concerning aspiration symptoms, nutritional and respiratory dysfunction, psychological disorders, and total scores (all P > 0.05). However, post-intervention, the study group showed significant improvements in these parameters and lower scores compared to the control group (all P < 0.05). Additionally, the study group demonstrated higher BMI, albumin (ALB), and hemoglobin (Hb) levels post-intervention (all P < 0.05), and a markedly lower incidence of aspiration and aspiration pneumonia (all P < 0.05). Conclusion Enhanced dysphagia assessment combined with dietary interventions significantly improves swallowing function, quality of life, and nutritional status in post-stroke dysphagia patients. This approach also reduces the incidence of related complications, suggesting substantial clinical benefits.

Addressing Systemic Complications of Acute Stroke: A Scientific Statement From the American Heart Association

Article

Dec 2024
STROKE

Systemic, nonneurological complications are common after ischemic and hemorrhagic strokes, affect different organ systems, and have a major impact on patient outcomes. Despite their obvious implications, this area in stroke management remains inadequately researched, and current literature offers fragmentary guidance for care. The purpose of this scientific statement is to elucidate the major systemic complications of strokes that occur during hospitalization, to synthesize evidence from current literature and existing guidelines, to address gaps in knowledge, and to provide a coherent set of suggestions for clinical care based on interpretation of existing evidence and expert opinion. This document advocates for improved interdisciplinary collaboration, team effort, and effective implementation strategies to reduce the burden of these events in clinical practice. It also calls for further research on strategies for preventing and managing systemic complications after stroke that improve outcomes in stroke survivors.

Surface Electromyographic Biofeedback and the Effortful Swallow Exercise for Stroke-Related Dysphagia and in Healthy Ageing

Article

Full-text available

Apr 2021
Dysphagia

Dysphagia is common after stroke, leading to adverse outcome. The Effortful Swallow (ES) is recommended to improve swallowing but it is not known if dysphagic patients can increase muscle activity during the exercise or if age affects performance. Providing surface electromyographic (sEMG) biofeedback during dysphagia therapy may enhance exercise completion, but this has not been investigated and the technique’s acceptability to patients is not known. Aims: To determine if age or post-stroke dysphagia affect the ability to increase submental muscle activity during the ES, if sEMG biofeedback improves ES performance and if sEMG is an acceptable addition to therapy. In a Phase I study submental sEMG amplitudes were measured from 15 people with dysphagia < 3 months post-stroke and 85 healthy participants aged 18–89 years during swallowing (NS) and when they performed the ES with and without sEMG biofeedback. Participant feedback was collected via questionnaire. Measurements were compared with repeated measures ANOVA and age effects were examined with linear regression. Both groups produced significantly greater muscle activity for the ES than NS (p < 0.001) and significantly increased activity with biofeedback (p < 0.001) with no effect of age. Participant feedback about sEMG was very positive; over 98% would be happy to use it regularly. The ES is a physiologically beneficial dysphagia exercise, increasing muscle activity during swallowing. sEMG biofeedback further enhances performance and is considered an acceptable technique by patients. These findings support the potential application of sEMG biofeedback and the ES in dysphagia therapy in stroke, justifying further investigation of patient outcome.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Article

Full-text available

Oct 2019

Background and Purpose— The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods— Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results— These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions— These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: An ecological analysis from the Global Burden of Disease Study 2017

Article

Full-text available

Oct 2019
BMC MED

Background: Socioeconomic status (SES) is associated with stroke incidence and mortality. Distribution of stroke risk factors is changing worldwide; evidence on these trends is crucial to the allocation of resources for prevention strategies to tackle major modifiable risk factors with the highest impact on stroke burden. Methods: We extracted data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. We analysed trends in global and SES-specific age-standardised stroke incidence, prevalence, mortality, and disability-adjusted life years (DALYs) lost from 1990 to 2017. We also estimated the age-standardised attributable risk of stroke mortality associated with common risk factors in low-, low-middle-, upper-middle-, and high-income countries. Further, we explored the effect of age and sex on associations of risk factors with stroke mortality from 1990 to 2017. Results: Despite a growth in crude number of stroke events from 1990 to 2017, there has been an 11.3% decrease in age-standardised stroke incidence rate worldwide (150.5, 95% uncertainty interval [UI] 140.3-161.8 per 100,000 in 2017). This has been accompanied by an overall 3.1% increase in age-standardised stroke prevalence rate (1300.6, UI 1229.0-1374.7 per 100,000 in 2017) and a 33.4% decrease in age-standardised stroke mortality rate (80.5, UI 78.9-82.6 per 100,000 in 2017) over the same time period. The rising trends in age-standardised stroke prevalence have been observed only in middle-income countries, despite declining trends in age-standardised stroke incidence and mortality in all income categories since 2005. Further, there has been almost a 34% reduction in stroke death rate (67.8, UI 64.1-71.1 per 100,000 in 2017) attributable to modifiable risk factors, more prominently in wealthier countries. Conclusions: Almost half of stroke-related deaths are attributable to poor management of modifiable risk factors, and thus potentially preventable. We should appreciate societal barriers in lower-SES groups to design tailored preventive strategies. Despite improvements in general health knowledge, access to healthcare, and preventative strategies, SES is still strongly associated with modifiable risk factors and stroke burden; thus, screening of people from low SES at higher stroke risk is crucial.

Predictive value of a novel pragmatic tool for post‐stroke aspiration risk: The Functional Bedside Aspiration Screen

Article

Full-text available

Jul 2019
NEUROGASTROENT MOTIL

Background There is still a strong need for an optimal clinician‐friendly screening tool for the identification of aspiration risk in stroke patients. In this study, we present the development of a novel, context‐specific screening tool for the prediction of aspiration risk on recent stroke survivors, the Functional Bedside Aspiration Screen (FBAS), and examine its construct validity, reliability with the predictive values toward pragmatic patients' outcomes. Methods We conducted a prospective validation study of 104 acute ischemic stroke patients admitted to clinical wards in a tertiary university hospital. A group of experts developed and administered the FBAS 10‐point scale to all patients. Outcome measures were compared with those of the validated Yale Swallow Protocol (YSP, reference measure) and health indicators. Key Results A strong association was found between the FBAS cutoff criterion and the YSP (Pearson χ² = 54.92, P < .001). A score of ≤8 on the FBAS presented with 93.3% sensitivity and 83.3% specificity in deeming patient with reduced safety for oral nutrition (AUC = 0.934, CI = 0.884‐0.985). An inverse relationship was found between performance on the FBAS and in‐hospital and long‐term outcome indicators. Patients who failed the FBAS were 1.82 times more likely to develop aspiration pneumonia (95% CI = 1.42‐2.35) and 1.35 times more likely to develop pneumonia within 3 months postonset (95% CI = 1.15‐1.59). Conclusions and Inferences The FBAS is a potentially useful tool for timely prediction of aspiration risk and health outcome in acute stroke.

Dysphagia screening tools for acute stroke patients available for nurses: A systematic review

Article

Full-text available

Jul 2019

Background & Aim: There is a high incidence of dysphagia after stroke that, depending on the assessment, methodology and time elapsed, can range from 8.1% to 80%. Early and systemic dysphagia screening is associated with a decreased risk of aspiration pneumonia and prevents inadequate hydration/nutrition. The purpose of this systematic review was to identify dysphagia screening tools for acute stroke patients available for nurses validated against reference test. The research question was: which dysphagia screening tools for acute stroke patients available for nurses? Methods & Materials: Three electronic databases were searched from January 2007 to November 2017: on PubMed, Scielo and CINAHL Plus. Two independent reviewers screened all titles and abstracts, assessed methodological quality and extracted data. The methodological quality analysis and evaluation was guided according to four domains: patient selection, index test, reference standard and flow and timing. Divergences between reviewers in data extraction were consensualized through discussion. Results: From the 377 articles retrieved, only three articles met criteria for review: Barnes-Jewish Hospital-Stroke Dysphagia Screen; the Gugging Swallowing Screen and, The Toronto Bedside Swallowing Screening Test. None of the screening tools complies with all psychometric properties, which means that a still significant proportion of patients will be kept nil by mouth without being necessary or that some patients will “fall through the cracks” interrupting the diagnostic process. The tools identified are different from each other, making their comparison impracticable. Conclusion: Due to psychometric proprieties and dietary recommendations adjusted to dysphagia severity, of all available tools, GUSS is a suitable screening tool for nurses in clinical practice.

Validity and reliability of the Turkish version of the Barnes-Jewish Hospital stroke dysphagia screen test in patients with acute stroke

Article

Full-text available

Jun 2019

Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

Article

Full-text available

May 2019
LANCET NEUROL

Summary Background Stroke is a leading cause of mortality and disability worldwide and the economic costs of treatment and post-stroke care are substantial. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic, comparable method of quantifying health loss by disease, age, sex, year, and location to provide information to health systems and policy makers on more than 300 causes of disease and injury, including stroke. The results presented here are the estimates of burden due to overall stroke and ischaemic and haemorrhagic stroke from GBD 2016. Methods We report estimates and corresponding uncertainty intervals (UIs), from 1990 to 2016, for incidence, prevalence, deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). DALYs were generated by summing YLLs and YLDs. Cause-specific mortality was estimated using an ensemble modelling process with vital registration and verbal autopsy data as inputs. Non-fatal estimates were generated using Bayesian meta-regression incorporating data from registries, scientific literature, administrative records, and surveys. The Socio-demographic Index (SDI), a summary indicator generated using educational attainment, lagged distributed income, and total fertility rate, was used to group countries into quintiles. Findings In 2016, there were 5·5 million (95% UI 5·3 to 5·7) deaths and 116·4 million (111·4 to 121·4) DALYs due to stroke. The global age-standardised mortality rate decreased by 36·2% (−39·3 to −33·6) from 1990 to 2016, with decreases in all SDI quintiles. Over the same period, the global age-standardised DALY rate declined by 34·2% (−37·2 to −31·5), also with decreases in all SDI quintiles. There were 13·7 million (12·7 to 14·7) new stroke cases in 2016. Global age-standardised incidence declined by 8·1% (−10·7 to −5·5) from 1990 to 2016 and decreased in all SDI quintiles except the middle SDI group. There were 80·1 million (74·1 to 86·3) prevalent cases of stroke globally in 2016; 41·1 million (38·0 to 44·3) in women and 39·0 million (36·1 to 42·1) in men. Interpretation Although age-standardised mortality rates have decreased sharply from 1990 to 2016, the decrease in age-standardised incidence has been less steep, indicating that the burden of stroke is likely to remain high. Planned updates to future GBD iterations include generating separate estimates for subarachnoid haemorrhage and intracerebral haemorrhage, generating estimates of transient ischaemic attack, and including atrial fibrillation as a risk factor.

Spontaneous Swallow Frequency as a Screening Protocol for Dysphagia in Acute Stroke (S32.004)

Article

Feb 2013

Failed Bedside Dysphagia Screen Predicts Pneumonia Treatment in Acute Stroke: A Resident Quality Initiative Project in a JC-Certified Primary Stroke Center (P3.124)

Article

Apr 2014

Accuracy and clinical utility of comprehensive dysphagia screening assessments in acute stroke: A systematic review and meta‐analysis

Article

Jan 2020

Introduction: Nurses and other nonspecialists in dysphagia are often trained to screen swallowing poststroke. There are many basic tools that test water only, they are usually conservative, and patients that fail the test remain nil by mouth until a speech and language therapy assessment. More comprehensive tests also allow nonspecialists to recommend modified oral intake. Little is known about the accuracy, clinical utility and cost-effectiveness of these tests. Methods: Following PRISMA guidelines, a systematic review was conducted to describe comprehensive swallowing tests that are available for use in acute stroke by nurses or other nonspecialists in dysphagia. A meta-analysis was performed to evaluate accuracy and the clinical utility of the tests was considered. Searches and analyses, conducted by two reviewers, included MEDLINE, Embase, trial registries and grey literature up to December 2018. Validated studies were assessed for quality and risk of bias using QUADAS-2. Results: Twenty studies were included, describing five different tests, three of which had undergone validation. The tests varied in content, recommendations and use. There was no test superior in accuracy and clinical utility. Three studies validating the Gugging Swallow Screen provided sufficient data for meta-analysis, demonstrating high sensitivity; 96% (95% CI 0.90-0.99), but low specificity, 65% (95% CI 0.47-0.79), in line with many water swallow tests. Results should be interpreted with caution as study quality and applicability to the acute stroke population was poor. Conclusions: There is no comprehensive nurse dysphagia assessment tool that has robustly demonstrated good accuracy, clinical utility and cost-effectiveness in acute stroke. Relevance to clinical practice: Nurses and other clinicians can develop competencies in screening swallowing and assessing for safe oral intake in those with poststroke dysphagia. It is important to use a validated assessment tool that demonstrates good accuracy, clinical utility and cost-effectiveness.

Screening for aspiration risk associated with dysphagia in acute stroke

Abstract

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