CTAR plus Effortful Swallow Simultaneously for Dysphagia Treatment:
1. Hold the ISO-SED by the red handle, with the red chest pad on your chest and the black chin pad pressed firmly under your chin.
2. Press your chin down into a CTAR (chin tuck against resistance) position against the resistance of the ISO-SED and hold for 30 seconds.
3. While holding this position, squeeze hard with all of your muscles and swallow hard.
4. Return to the starting position.
5. Repeat this exercise 10-20 times per session, until the suprahyoid muscles under the chin are fatigued.
Each of these exercises, CTAR (Chin Tuck Against Resistance) and the Effortful Swallow have been used for dysphagia treatment separately. They can be combined into an Effortful Swallow Against Resistance exercise to increase time efficiency and intensity of both exercises, by pushing the muscles to do more as a combined exercise than either one does individually.
In 2015 Kraaijenga conducted a study using a Swallowing Exercise Aid device in connection with three exercises: Chin Tuck Against Resistance (CTAR), Jaw Opening Against Resistance (JOAR) and effortful swallow with resistance. They measured outcomes with a dynamometer (IOPI), MRI and VFSS, for the following: maximum chin tuck and jaw opening strength, maximum tongue strength and endurance, suprahyoid mass, and hyoid bone displacement. The authors concluded, "Outcomes measured following 6 weeks of exercise indicated a significant increase in all of the above...."(1).
The Effortful Swallow Maneuver is a dysphagia treatment exercise for increasing tongue base retraction and pharyngeal pressure during the swallow for reduced residue in the valleculae (2). To complete an Effortful Swallow Maneuver, squeeze hard with all of your muscles as you swallow.
Research of the Effortful Swallow Maneuver in healthy normal adults indicated significantly higher oral pressures, decreased oral residue and increased hyoid excursion and elevation during the effortful swallows (3). Research has also shown increased duration of pharyngeal pressure and increased duration of upper esophageal sphincter (UES) relaxation (4).
In a 2013 study by Wai Lam Yoon, the surface EMG activity of the suprahyoid muscles was compared between the Chin Tuck Against Resistance (CTAR) exercise and the Shaker exercise. During the CTAR exercise, the participant tucked the chin against the resistance of an inflatable rubber ball while in a seated position. There were 40 participants in this study, 20 males and 20 females. The results showed significantly greater maximum SEMG values during the Chin Tuck Against Resistance isokinetic and isometric exercises than during the equivalent Shaker exercises. The authors concluded that Chin Tuck Against Resistance exercises appear to be effective in exercising the suprahyoid muscles and therapeutic effects could be comparable to those of the Shaker exercise. They also found that clients reported the Chin Tuck Against Resistance exercises were less strenuous than the Shaker exercise and these exercises therefore have the potential for greater compliance by patients than the Shaker exercise (5).
1. Kraaijenga, SAC, et al. Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects: A Prospective Effectiveness and Feasibility Study. Dysphagia (2015) DOI: 10.1007/s00455-015-9611-8.
2. Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. Pro-Ed; Austin, TX: 1998.
3. Hind JA, Nicosia MA, Roecker EB, et al. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. 2001;82(12):1661–5. [PubMed]
4. Hiss SG, Huckabee ML. Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia. 2005;20(2):149–56. [PubMed]
5. Yoon, W. L., Khoo, J. K. P., Rickard Liow, S. J. (2014). Chin Tuck Against Resistance (CTAR): New method for enhancing suprahyoid muscle activity using a Shaker-type Exercise. Dysphagia, 29(2), 243-248. doi: 10.1007/s00455-013-9502-9
See www.alternativespeech.com for more information on related research, such as CTAR, JOAR, and other dysphagia exercises.
ABOUT THE AUTHOR:
Jolie Parker, M.S.CCC-SLP received her Bachelor of Science in Communication Disorders from the University of Florida and then went on to receive her Master of Science in Speech-Language Pathology also from the University of Central Arkansas. She specializes in the treatment of people who have dysphagia, or difficulty swallowing symptoms, such as: difficulty swallowing food, coughing or choking while eating, difficulty swallowing pills, coughing or choking when drinking liquids, recurrent lung infections or aspiration pneumonia. She is a co-inventor of the ISO Swallowing Exercise Device. Many of her dysphagia patients have been on PEG tubes, mechanical soft diets, pureed diets, and/or thickened liquids and have returned to regular foods and liquids after completing dysphagia exercises with the ISO Swallowing Exercise Device, including CTAR (Chin Tuck Against Resistance), JOAR (Jaw Opening Against Resistance), Effortful Swallow Against Resistance, and other dysphagia exercises.
Jolie provides home therapy visits for adults and children with dysphagia in the central Florida area. She holds a Certificate of Clinical Competence from the American Speech-Language and Hearing Association (ASHA), a state license from the Florida Department of Health, and has 20 years of experience in clinical settings, hospitals, nursing homes, and home health care. She is the author of the ASHA approved CEU course for speech language pathologists: Using the ISO Swallowing Exercise Device in Dysphagia Therapy.