The Test of Masticating and Swallowing Solids (TOMASS): reliability, validity and international normative data
Authors: Huckabee Maggie‐Lee , McIntosh Theresa , Fuller Laura , Curry Morgan , Thomas Paige , Walshe Margaret , McCague Ellen , Battel Irene , Nogueira Dalia , Frank Ulrike , van den Engel‐Hoek Lenie , Sella‐Weiss Oshrat 
Published: July 2017

AbstractBackgroundClinical swallowing assessment is largely limited to qualitative assessment of behavioural observations. There are limited quantitative data that can be compared with a healthy population for identification of impairment. The Test of Masticating and Swallowing Solids (TOMASS) was developed as a quantitative assessment of solid bolus ingestion.AimsThis research programme investigated test development indices and established normative data for the TOMASS to support translation to clinical dysphagia assessment.Methods & ProceduresA total of 228 healthy adults (ages 20–80+ years) stratified by age and sex participated in one or more of four consecutive studies evaluating test–retest and interrater reliability and validity to instrumental assessment. For each study the test required participants to ingest a commercially available cracker with instructions to ‘eat this as quickly as is comfortably possible’. Further averaged measures were derived including the number of masticatory cycles and swallows per bite, and time per bite, masticatory cycle and swallow. Initial analyses identified significant differences on salient measures between two commercially available crackers that are nearly identical in shape, size and ingredients, suggesting the need for separate normative samples for specific regional products. Additional analyses on a single cracker identified that the TOMASS was sensitive at detecting changes in performance based on age and sex. Test–retest reliability across days and interrater reliability between clinicians was high, as was validation of observational measures to instrumental correlates of the same behaviours. Therefore, normative data are provided for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide.Outcomes & ResultsAnalyses on a single cracker identified Arnott's Salada, and that TOMASS measures were sensitive for detecting changes in performance based on age and sex. Interrater and test–retest reliability across days were high, as was validation of observational measures to instrumental correlates of the same behaviours. Significant differences were identified between two commercially available crackers, nearly identical in shape, size and ingredients, thus normative samples for specific regional products were required. Normative data were then acquired for the TOMASS from a minimum of 80 healthy controls, stratified by age and sex, for each of seven commercially available crackers from broad regions worldwide.Conclusions & ImplicationsThe TOMASS is presented as a valid, reliable and broadly normed clinical assessment of solid bolus ingestion. Clinical application may help identify dysphagic patients at bedside and provide a non‐invasive, but sensitive, measure of functional change in swallowing.