Dysphagia

https://doi.org/10.1007/s00455-020-10167-2

ORIGINAL ARTICLE

Translation and Validation of the TOR‑BSST© into Brazilian Portuguese

for Adults with Stroke
Aline Cristina Pacheco‑Castilho1 · Gabriela de Martini Vanin2 · Beatrix Reichardt2 ·
Rubia Poliana Crisóstomo Miranda3 · Ana Maria Queirós Norberto4 · Monica Carvalho Braga1 ·
Thatiana Barboza Carnevalli Bueno1 · Karina Tavares Weber1 · Taiza Elaine Grespan Santos1 · João Pereira Leite1 ·
Roberto Oliveira Dantas4 · Octávio Marques Pontes‑Neto1 · Rosemary Martino2,5,6,7,8,9

Received: 3 May 2020 / Accepted: 17 July 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Brazil has a higher rate of dysphagia in stroke patients compared to developed countries, but does not have a fully validated
method for early identification of dysphagia in this population. The aim of this study is to translate the TOR-BSST© into
Brazilian Portuguese and assess the newly translated version for reliability and validity with Brazilian adult patients with
stroke. The translation of the TOR-BSST© followed a multi-step process, according to the International Quality of Life
Assessment project. For validation, we included patients with age ≥ 18 years and stroke diagnosis confirmed by neuroimaging
and tolerance for videofluoroscopic swallowing assessment. The BR-PTfinal TOR-BSST© was administered by two trained
screeners within two hours of videofluoroscopy. All assessors were independent and blinded. Estimates for reliability used
the intraclass correlation coefficient (ICC) and for accuracy both sensitivity (SN) and negative predictive (NP) values were
used, along with 95% confidence intervals (CI). Sixty patients were enrolled and tested for a mean (SD) of 14.4 (6.9) days
from last seen normal. Of all the patients, 41 (68.3%) failed the BR-PTfinal TOR-BSST© and 21 (35%) were scored to have
dysphagia on videofluoroscopy, of which 11 (52.4%) had mild dysphagia. The overall reliability between screeners was
satisfactory (ICC = 0.59; 95% CI 0.32 to 0.76). The SN and NP values for the BR-PTfinal TOR-BSST© were 85.7% (95%
CI 0.62–0.96) and 84.2% (95% CI 0.72–0.95), respectively. The TOR-BSST© was successfully translated to Brazilian Por-
tuguese with the BR-PTfinal TOR-BSST© proven to have high sensitivity and negative predictive values when compared to
gold standard videofluoroscopy.

Keywords Deglutition · Deglutition disorders · Dysphagia · Screening · Stroke · Brazil

Introduction for expert assessment and treatment by a Speech Language

Stroke is the leading cause of disability and the second cause
of mortality in Brazil [1–4]. There is evidence that early
detection of dysphagia in patients with stroke can reduce
medical complications [5–7], length of hospital stay, and
health care costs [6]. The benefits from early detection are
realized when screening accurately and systematically iden-
tifies patients with dysphagia and then triggers a referral
Both Octávio Marques Pontes-Neto and Rosemary Martino are
equally contributed as last author of this manuscript
* Aline Cristina Pacheco‑Castilho
alinecpacheco_usp@yahoo.com.br
Extended author information available on the last page of the article
Pathologist (SLP) [8].
Compared to developing countries, Brazil has a higher
rate of dysphagia in patients with stroke [9, 10]. In keep-
ing with stroke guidelines from Canada [11] and the USA
[12], Brazilian guidelines recommend that all stroke patients
are to be screened for dysphagia and if results are positive
then they are referred and treated by dysphagia SLP experts
[13]. Recently, two Brazilian studies [14, 15] were published
with screening tools for dysphagia. However, only one [14]
was tested with stroke patients and validated for content,
but not accuracy or reliability. Thus, to date, Brazil does not
have a fully validated method for early identification of dys-
phagia in patients with stroke available for implementation
across all publicly funded hospitals. This potentially leaves
a substantial population of patients with stroke vulnerable

13
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 A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil

to dysphagia-related complications that could otherwise be Original TOR-BSST© Form

avoided. CA-ENorig
There are currently several dysphagia screening tools for
patients with stroke available for English speaking countries
CA-ENorig → BR-PTfwd1 CA-ENorig → BR-PTfwd2
[16, 17]. Of these, the Toronto Bedside Swallowing Screen- Translator 1 Translator 2
ing Test (TOR-BSST©) is one of the few that was properly
developed and validated [18]. The English TOR-BSST© has
proven feasibility and reliability when administered by any Reconciliaƒon
trained healthcare member and accurately identifies stroke Translator 3

PHASE A
patients at risk for dysphagia in both the acute and rehabili-
tation setting [18]. BR-PTfwd-rec
In contrast, there is to date no such tool adequately vali- Reconciled Forward Translaƒon

dated for the Brazilian stroke population [19]. The utiliza-

tion of a Portuguese dysphagia screening tool in Brazil will BR-PTfwd-rec → CA-ENback
Translator 4
promote adherence to stroke guidelines and help mitigate
unnecessary health consequences for these patients. Given
the availability of the English TOR-BSST© with already
Review/Comparison of Review/Comparison of
proven excellent psychometric properties, the aim of this CA-ENorig & CA-ENback CA-ENorig & CA-ENback
study was twofold: i. translate the TOR-BSST© into Brazil- Translator 3 Swallowing Lab

ian Portuguese and ii. assess the newly translated version for
PHASE B
reliability and validity with Brazilian patients with stroke. Resolve Discrepancies
Translator 3

Materials and Methods BR-PT1

FIRST RECONCILED DRAFT

Translation of the TOR‑BSST©

The translation of the TOR-BSST© from Canadian Eng- In-Country In-Country Review In-Country
lish (CA-EN) to Brazilian Portuguese (BR-PT) followed a Review of BR-PT1 of BR-PT1 Review of BR-PT1
multi-step process, according to the International Quality
of Life Assessment (IQOLA) project [20]. The Interpreta-
PHASE C

tion and Translation Services department (ITS) at the Uni- Reconciliaƒon

ITS
versity Health Network (Toronto, ON, Canada) has specific
expertise in translation of health-related documents and was
contracted to carry out the translation. BR-PT2
SECOND RECONCILED DRAFT
The literal translation and cultural adaptation from
CA-EN to the final draft of the BR-PT followed four sequen-
In-Country Review and
tial phases according to published IQOLA standards (Fig. 1): Revision of BR-PT2
Phase A: Forward translation (CA-ENorig to BR-PTfwd) by
PHASE D

SLP 4
two independent fluent speakers of both languages (Transla-
tor 1 and 2); reconciliation of any differences between the BR-PTfinal
two BR-PT translations (BR-PTfwd1 and BR-PTfwd2) by a THIRD/FINAL RECONCILED DRAFT

third translator also fluent in both languages (Translator 3);

generating a reconciled forward translation (BR-PTfwd-rec);
and back translation (BR-PTfwd-rec to CA-ENback) of the rec-
onciled forward translation by a fourth translator fluent in
both languages (Translator 4). Phase B: Review and compar-
ison of the original TOR-BSST© (CA-ENorig) with the back
translation (CA-ENback), including input from Translator 3
and researchers who developed the original TOR-BSST©
(CA-ENorig) to ensure accuracy, discuss any discrepancies,
and generate the first reconciled draft of the BR-PT transla-
tion (BR-PT1). Phase C: First in-country review by three
Fig. 1  Translation and cultural adaptation from CA-EN to the final
draft of the BR-PT followed four sequential phases according to the
published IQOLA standards
clinically active SLPs from Brazil, whose first language
was BR-PT. These clinicians independently reviewed the
first reconciled draft for contextual and cultural appropriate-
ness. Feedback from each SLP was forwarded to ITS who
reviewed and incorporated their feedback to create a second

13
A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil

reconciled draft of the BR-PT translation (BR-PT2). Phase
D. Second in-country review by a fourth SLP, whose first
language was BR-PT and who revised the second reconciled
translation to create the third and final reconciled translation
(BR-PTfinal).
Analysis of the Translation Process
Translator feedback of the BR-PT versions that directed revi-
sions was documented during each Phase of the translation
and cultural adaptation process. Two SLPs independently
reviewed each revision and categorized it into three primary
types: an “error” in translation, an “improvement” in transla-
tion, or a “neutral” change in translation based solely on per-
sonal lexical preference of the translator. More specifically,
“errors” and “improvements” were then sub-categorized
further (see Table 1). Any differences between ratings were
reconciled with a third SLP.
Stroke Patients
All consecutive stroke patients admitted to the emer-
gency unit of a tertiary academic hospital in Brazil were
approached for consent. Eligible patients were those that
met the following criteria: age ≥ 18 years; stroke diagnosis
confirmed by CT scan and/or MRI findings; able to toler-
ate videofluoroscopy assessment (VFS) of their swallowing
(namely, this necessitated patients to be alert, sit upright
with or without support, follow one-step commands, and
be willing to receive a VFS exam at an outpatient clinic).
Patients were excluded if they were obtunded, with poor
support, not acute (> 10 days post last seen normal) or not
consenting.
Dysphagia Screeners
Two healthcare professionals, both physiotherapists, were
trained by a SLP on administration and interpretation of
the BR-PTfinal TOR-BSST© with stroke patients. The BR-
PTfinal TOR-BSST© screener training was administered
according to a standardized protocol [18]. First, the Research
Coordinator (RC) of the study, also a SLP, received the
standardized 4-h webinar didactic training on administra-
tion and interpretation of BR-PTfinal TOR-BSST© along with
strategies for implementation in a clinical setting. Next, the
RC administered the standardized live TOR-BSST© screener
training to the two physiotherapists, using a 4-h didactic
course followed by observation at the bedside to ensure
competency. All BR-PTfinal TOR-BSST© training material
had been translated into BR-PT. Didactic training included
a review of basic anatomy and physiology of swallow-
ing, strategies to administer the BR-PTfinal TOR-BSST© to
patients with aphasia, and procedures on how to interpret
the screening results using video-taped real-life examples
of 5 stroke patients being administered the BR-PTfinal TOR-
BSST©. Screeners were also trained to determine whether
patients met the criteria for dysphagia screening, namely, if
they were alert, if they were able to follow simple one-step
commands, if they were able to sit upright, and if they had
recent oral care. Live competency testing included individ-
ual training at the patient’s bedside where screener trainees
independently administered the BR-PTfinal TOR-BSST© to 5
stroke patients with the supervision of the RC. Trainees were
required to pass all levels of the BR-PTfinal TOR-BSST©
training before participating in the study.
Procedure
All the patients that met the inclusion criteria and admitted
to hospital between April 2015 and September 2015 were
identified and screened for eligibility. If eligible, they were
contacted by phone soon after discharge from the acute hos-
pital and approached. All those who consented were invited
to be tested using VFS as an outpatient. On the day of test-
ing, the VFS was administered by a clinical SLP and the BR-
PTfinal TOR-BSST© was independently administered by two
trained screeners. The VFS and both BR-PTfinal TOR-BSST©
screens were administered on the same day by independent
and blinded raters with no knowledge of each other’s find-
ings or patient medical information except for the diagnosis
of stroke. The study was approved by the Institutional Ethics

Table 1  Categories of revision types with definitions

Revision category Definition

(1) Error A change that significantly altered the original meaning/intention

i. Alteration A change that failed to reflect words, information or data contained in the previous version
ii. Omission
(2) Improvement A change that added necessary details, which may or may not have added more words
i. Clarification A change that more authentically expressed the idea in the target language
ii. Cultural adaptation
(3) Neutral A change that replaced or added a word(s) without changing the overall meaning
i. Lexical preference

13
 A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil
Committee and all patients, or substitute decision-makers,
gave informed consent.
Index Testing
The BR-PTfinal TOR-BSST© consists of four assessment
items: the first item assesses the patient’s vocal quality
before swallowing to identify any abnormalities such as
breathiness, gurgliness, hoarseness, or whisper quality; the
second item assesses tongue movement, identifying any
asymmetry upon protrusion or lateralization; the third item
includes sequential screener-led administration of 10 tea-
spoons of water followed by a patient self-administered cup
sip to identify clinical signs of bolus misdirection, such as
coughing, drooling, or change in the voice quality; and the
fourth item assesses the vocal quality one minute after liquid
swallows, again to identify any signs of voice change. Each
item on the TOR-BSST© is scored as a binary abnormal/
normal, and any abnormal score on the test identifies the
patient to be at high dysphagia risk.
Criterion Reference Testing
The VFS served as the criterion reference by which we
determined accuracy of the TOR-BSST© screening tool.
Administration of the VFS exam included a variety of con-
sistencies in the following order: liquid, nectar, honey, paste,
and solid. We used 33.3 ml of Bariogel® with 66.7 ml of
water to prepare the thin liquid. This preparation was then
mixed with a thickener to produce the modified liquid and
paste consistencies. It was also mixed with solid to ensure
radio-opaque visibility during the digital capture. Liquid and
nectar consistencies were administered first using controlled
volumes (2 × tsp of 5 ml) and then in free volume patient
self-modulated sips. Honey and paste consistencies were
each administered twice using controlled single tsp of 5 ml
mouthfuls. Lastly, a solid cookie consistency was admin-
istered asking the patient to take a single bite. VFS testing
was discontinued if/when the administrator (a SLP) had any
safety concerns, such as noting moderate to significant aspi-
ration with any food stimuli. All VFSs were recorded and
digitally captured at 30 frames per second.
The digital images of the VFSs were carefully reviewed
and scored by an expert clinical SLP, who was blinded to
both of the BR-PTfinal TOR-BSST© results. First, the SLP
assessed each administered bolus stimuli for presence or
absence of the following impairments: anterior escape of
the bolus from the lips; poor bolus control in the oral cavity;
uncoordinated bolus preparation and/or posterior transporta-
tion; oral residue; poor airway safety marked by penetration
and/or aspiration; and any pharyngeal residue. The SLP then
derived an overall score across all textures according to the
Dysphagia Outcome Severity Scale (DOSS) [21]. In order
13
to derive a binary score, DOSS scores between 1 and 5 were
deemed to have dysphagia (present),whereas DOSS scores
between 6 and 7 were deemed to have no dysphagia (absent).
Reliability
Inter-rater reliability for the total BR-PTfinal TOR-BSST©
score was assessed between the two trained screeners for
all patients.
Data Analysis
Patient demographics and stroke characteristics were sum-
marized descriptively using frequencies, percentages,
means, standard deviations (SDs), medians, and interquar-
tile ranges (IQRs). Accuracy measures of the BR-PTfinal
TOR-BSST© were summarized using sensitivity, specific-
ity, likelihood ratios, and predictive values, along with their
95% confidence intervals for the total TOR-BSST© score.
Inter-rater reliability was assessed using the intraclass cor-
relation coefficient (ICC). SPSS software (version 20) [22]
was used to perform all statistical analyses, setting alpha at
0.05 and power at 0.80.
Results
Translation of the TOR‑BSST©
The four phases of the translation and cultural adaptation
of the TOR-BSST© from Canadian English (CA-ENorig) to
Brazilian Portuguese (BR-PTfinal) were completed.
Analysis of the Translation Process
The number of translation revisions was summarized by
category according to each of the four phases (Table 2).
Across all categories and phases, the most common revi-
sion addressed rater preference and the least common a
translation error. Regardless of revision category, at each
advancing phase in the translation process, the total number
of revisions decreased steadily. Ultimately, in the final phase,
a total of two revisions were registered.
Stroke Participants
A total of 270 patients were admitted to hospital (Fig. 2).
We excluded 119 patients based on our a priori exclusion
criteria, namely, 20 due to diagnosis of Transient Ischemic
Attack, 14 were not diagnosed with stroke, 7 had strokes for
greater than ten days, 6 suffered cerebral venous thrombo-
ses, 45 died in hospital, and 27 were unable to tolerate VFS.
Among the eligible patients, 31 refused or were unable to
A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil

Table 2  Revision types by Revision type

phase
Error Improvement Neutral Total
ALT OM CLA CULT

Phase A 6 0 13 3 42 64
Phase B 4 3 4 0 8 19
Phase C 2 0 3 1 7 13
Phase D 0 0 1 0 1 2
Total 12 3 21 4 58 98

ALT alteration, OM omission, CLA clarification, CULT cultural adaptation

Fig. 2  Flow chart of the valida- Patients admitted

tion study n=270 Excluded patients n=119
Transient Ischemic Attack n=20
Non-stroke n=14
Not acute stroke (>10 days) n= 7
Cerebral venous thrombosis n=6
Hospital death n=45
Unable to tolerate VFS n=27

Patients eligible Patients refused or unable to obtain consent n=31

n=151 Not available to go to the VFS exam site n=60

Patients assessed
n=60

TOR-BSST© normal n=19 TOR-BSST© abnormal n=41

Dysphagia Dysphagia Dysphagia Dysphagia

present at absent at present at absent at
VFS VFS VFS VFS
n=3 n=16 n=18 n=23

obtain consent and 60 were not available to go to the VFS
exam site. Ultimately, 60 patients were enrolled and assessed
for swallowing with both the BR-PTfinal TOR-BSST© and
VFS. The demographic, clinical, and stroke characteristics
for these patients are presented in Table 3. The mean (SD)
number of days from last seen normal to discharge from
acute hospital was 5.2 (3.4) days. The mean (SD) number
of days from the last seen normal to BR-PTfinal TOR-BSST©
screening and VFS assessment was 14.4 (6.9) days (Table 3).
Index Testing
Of all the stroke patients assessed, 41 (68.3%) failed the
BR-PTfinal TOR-BSST©. Among them, 12 (29.3%) failed
the vocal quality check before swallowing, 9 (21.9%)
failed on tongue movement, 17 (41.5%) failed during
the swallowing trials, and 3 (7.3%) failed on the vocal
quality check following the liquid swallows. The overall
agreement between screeners was satisfactory, with a total
score intraclass correlation coefficient (ICC = 0.59; 95%
CI 0.32–0.76).
Criterion Reference Testing
Across all patients, 21 (35%) were scored to have dysphagia
on VFS. Of these, 11 (52.4%) patients had mild dysphagia
(DOSS level 5), 6 (28.6%) patients had moderate dysphagia
(DOSS level 4 and 3), and 4 (19%) patients had severe dys-
phagia (DOSS level 2 and 1). The sensitivity, specificity,
positive predictive (PP) values, and negative predictive (NP)
values for the BR-PTfinal TOR-BSST© were 85.7% (95% CI

13
 A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil

Table 3  Demographic, clinical, and stroke characteristics of patients Discussion

assessed
Values In Brazil, dysphagia screening tools have to date been
administered to stroke patients using institutional pro-
Agea, mean years ± SD 64.9 ± 13
tocols without validation. According to Donovan et al.
Male, n (%) 33 (55%)
(2013) [23], the use of poorly validated screening tests
History of s­ trokea, n (%) 14 (26.9%)
should be avoided as their accuracy to detect dysphagia
Stroke ­typea, n (%)
may be suboptimal, thereby missing patients with swal-
Ischemic 47 (88.7%)
lowing problems. The translation and adaptation of a test
Bamford ­classificationc, n (%)
does not in itself guarantee that it is valid for use in a
TACS 7 (13%)
given population without a formal validation analysis
PACS 17 (31.5%)
[24]. Therefore, this study followed a well-established
LACS 24 (44.4%)
translation [20] of the TOR-BSST© and then validated the
POCS 6 (11.1%)
BR-PTfinalTOR-BSST© to ensure adequate accuracy in the
Injured ­hemisphered, n (%)
Brazil-speaking hospital setting.
Right 26 (55.3%)
Our findings compared the new BR-PTfinal TOR-BSST©
Left 21 (44.7%)
to VFS, the universally accepted gold standard test to iden-
Stroke severity, median [IQR]
tify the presence and severity of dysphagia in patients with
NIHSS at admission 5 (3–11)
stroke. Both the screening and gold standard tests were
NIHSS at ­dischargeb 2 (1–7)
applied during the subacute phase and showed excellent
LSN to discharge, mean days (SD) 5.2 (3.4)
sensitivity and negative predictive values of 85.7% and
LSN to discharge, median days [IQR] 4.5 (3–6)
84.2%, respectively, thereby meeting the standards for
LSN to TOR-BSST©/VFS, mean days (SD) 14.4 (6.9)
clinical tools [25]. These results provide a translated, cul-
LSN to TOR-BSST©/VFS, median days [IQR] 13.5 (18–19)
turally adapted, and validated dysphagia screening tool,
TACS total anterior circulation stroke, PACS partial anterior circula- namely, the BR-PTfinal TOR-BSST©, for implementation
tion syndrome, LACS Lacunar Syndrome, POCS Posterior Circula- in stroke units across Brazil that adheres with national
tion Syndrome, NIHSS National Institutes of Health Stroke Scale,
guidelines.
LSN last seen normal, TOR-BSST© Toronto Bedside Swallowing
Screening Test, VFS videofluoroscopy A limitation of this study is that in keeping with the
a
Missing values: 7 patients current standard of practice, we performed the screen-
b
Missing values: 3 patients ing and gold standard tests during the subacute phase of
c
Missing values: 6 patients stroke. Although this timing may have missed more severe
d
Missing values: 13 patients dysphagia in the early acute phase, it served to potentially
yield more conservative accuracy results due to a lower
prevalence of dysphagia in the subacute stroke [25]. This
0.62–0.96), 41.0% (95% CI 0.25–0.57), 43.9% (95% CI then gives clinicians confidence that if the BR-PTfinal TOR-
0.29–0.58), and 84.2% (95% CI 0.72–0.95), respectively BSST© is implemented in early acute stroke, as guidelines
(Table 4). recommend, it is expected to meet and perhaps surpass

Table 4  Accuracy measures of VFS (n = 60)

the TOR-BSST©
Dysphagia No dysphagia
©
TOR-BSST

Dysphagia 18 23 PPV = 43.9%

(95% CI, 29 to 58)
NPV = 84.2%
(95% CI 72–95)
No dysphagia 3 16 + LR = 1.45 (95%
Sensitivity = 85.7% Specificity = 41.0% CI 1.06–1.99)
(95% CI 62–96) (95% CI 25–57) − LR = 0.34 (95%
False negative = 15% False positive = 59% CI 0.11–1.05)
Prevalence = 35%

TOR-BSST© Toronto Bedside Swallowing Screening Test, VFS videofluoroscopy

13
A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil
the accuracy herein reported. Throughout our study, we
adhered to rigorous design in an effort to mitigate any
other sources of bias and were vigilant to control for blind-
ing of all assessors.
In conclusion, the TOR-BSST© was successfully trans-
lated to Brazilian Portuguese, yielding the BR-PTfinal TOR-
BSST©. The BR-PTfinal TOR-BSST© was proven to have
high sensitivity and negative predictive values when com-
pared to the gold standard VFS, thereby establishing it as
a properly validated tool for administration with Brazilian
patients with stroke.
Author Contributions The authors participated sufficiently in the work
to take public responsibility for appropriate portions of the content.
The effort by each author based on the contributions to the study is
described below: Concept and design: ACP-C, ROD, OMP-N, and RM.
Conduct of translation: BR, GMV and RM. Conduct of validation:
ACP-C, RPCM, AMQN, MCB, TBCB, and KTW. Data analysis: ACP-
C, TEGS, JPL, ROD, OMP-N, and RM. Manuscript writing: ACP-C,
BR, TEGS, JPL, ROD, OMP-N, and RM.
Funding: This work was completed with support to Aline Cristina
Pacheco-Castilho from Coordination of Improvement of Higher Level
Personnel (CAPES); support to Octávio Marques Pontes-Neto from
National Council of Scientific and Technological Development of
Brazil (CNPq – 482721/2013-8 and 402388/2013-5); and support to
Rosemary Martino from her Canada Research Chair (Tier II) in Swal-
lowing Disorders (CIHR 950-231997).
Compliance with Ethical Standards
Conflict of interest The authors Aline C Pacheco-Castilho, Beatrix
Reichardt, Gabriela M Vanin, Rubia P C Miranda, Ana Maria Q Nor-
berto, Monica C Braga, Thatiana B C Bueno, Karina T Weber, Taiza E
G Santos, João P Leite, Roberto O Dantas, and Octávio M Pontes-Neto
declared no potential conflicts of interest with respect to the research,
authorship, and publication of this article. Rosemary Martino is the
developer of the TOR-BSST© tool.
Research Ethics Committee and Informed Consent: This study was
performed after approval by the appropriate Research Ethics Commit-
tee and written informed consent was obtained from all participants.
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 A.C. Pacheco-Castilho et al.: Translation and Validation of the TOR-BSST© in Brazil

Publisher’s Note Springer Nature remains neutral with regard to Thatiana Barboza Carnevalli Bueno BSc
jurisdictional claims in published maps and institutional affiliations.
Karina Tavares Weber PhD

Taiza Elaine Grespan Santos PhD

Aline Cristina Pacheco‑Castilho PhD
João Pereira Leite MD, PhD
Gabriela de Martini Vanin MSc
Roberto Oliveira Dantas MD, PhD
Beatrix Reichardt MHSc
Octávio Marques Pontes‑Neto MD, PhD
Rubia Poliana Crisóstomo Miranda MSc
Rosemary Martino PhD
Ana Maria Queirós Norberto PhD

Monica Carvalho Braga BSc

Affiliations

Aline Cristina Pacheco‑Castilho1 · Gabriela de Martini Vanin2 · Beatrix Reichardt2 ·

Rubia Poliana Crisóstomo Miranda3 · Ana Maria Queirós Norberto4 · Monica Carvalho Braga1 ·
Thatiana Barboza Carnevalli Bueno1 · Karina Tavares Weber1 · Taiza Elaine Grespan Santos1 · João Pereira Leite1 ·
Roberto Oliveira Dantas4 · Octávio Marques Pontes‑Neto1 · Rosemary Martino2,5,6,7,8,9
1
Beatrix Reichardt Department of Neurosciences and Behavioral Sciences,
trixie.reichardt@utoronto.ca Ribeirão Preto Medical School, University of São Paulo, Av.
Bandeirantes 3900, Ribeirão Preto, SP 14049‑900, Brazil
Rubia Poliana Crisóstomo Miranda
2
rubiapoliana@hotmail.com Speech‑Language Pathology, University of Toronto, Toronto,
ON, Canada
Ana Maria Queirós Norberto
3
anamariaqn@yahoo.com.br Department of Ophthalmology, Otorhinolaryngology
and Head and Neck Surgery, Ribeirão Preto Medical School,
Monica Carvalho Braga
University of São Paulo, Ribeirão Preto, Brazil
monica.braga@fmrp.usp.br
4
Department of Medicine, Ribeirão Preto Medical School,
Thatiana Barboza Carnevalli Bueno
University of São Paulo, Ribeirão Preto, Brazil
thatigpe@hotmail.com
5
Department of Speech‑Language Pathology, Faculty
Karina Tavares Weber
of Medicine, University of Toronto, Toronto, Canada
ka_tavares@hotmail.com
6
Swallowing Lab, University of Toronto, Toronto, ON,
Taiza Elaine Grespan Santos
Canada
taiza@usp.br
7
Rehabilitation Science Institute, University of Toronto,
João Pereira Leite
Toronto, ON, Canada
jpleite@fmrp.usp.br
8
Krembil Research Institute, University Health Network,
Roberto Oliveira Dantas
Toronto, ON, Canada
rodantas@fmrp.usp.br
9
Otolaryngology Head and Neck Surgery, University
Octávio Marques Pontes‑Neto
of Toronto, Toronto, ON, Canada
ompneto@gmail.com
Rosemary Martino
rosemary.martino@utoronto.ca

13