According to Cochrane methodology,26 we assessed each study for risk of bias and poor study design to generate a quality GRADE (Table 2). Of the 14 included studies, one study42 had the lowest risk of bias, with only one area receiving a rating of unclear. Of the three randomized trials, one study41 had adequate sequence generation and allocation concealment. Only one other study40 declared blinding. All 14 studies accounted for their outcomes, but only eight specifically declared consecutive enrollment.3,4,18-20,36,42,43 Outcomes were operationally defined in four studies,4,20,41,42 whereas only eight studies3,4,32,37-40,42 conducted the same swallow assessment for all study enrollees. All studies received a high or unclear risk of bias rating in at least one area. Additionally, each study had factors that decreased the quality of the evidence such as insensitive swallowing assessment measures,32,37,38,40 small sample size of fewer than 50 enrollees,3,32,37,39,40,42 and different types of swallowing assessment for enrollees.18-20,36,43 As a result, each study in this review was assigned a GRADE of very low.