Click here for a copy of The CTAR Quick Reference Guide for Clinicians.   

A Look Back at the Origins

Back in 2014, the dysphagia world was introduced to a novel exercise: the Chin Tuck Against Resistance (CTAR). First published in Dysphagia, this exercise was designed to strengthen the suprahyoid muscles, which are critical for hyolaryngeal excursion and upper esophageal sphincter (UES) opening—key components of a safe and effective swallow.

For patients with pharyngoesophageal segment (PES) dysfunction, exercises targeting these muscles can lead to improved swallow physiology and reduced post-swallow residue. CTAR was developed as an alternative to the traditional Shaker exercise, aiming to provide a more accessible and patient-friendly approach.

Want your own CTAR Quick Reference Guide for Clinicians?   Click the link to download!

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CTAR vs. Shaker: What’s the Difference?

Both CTAR and the Shaker exercise include isometric and isokinetic components, but the execution and patient experience are quite different.

Shaker Exercise:

• Isometric: Lifting and holding the head off the floor for 60 seconds, followed by a 60-second rest (×3 reps).

• Isokinetic: 30 repetitions of lifting and lowering the head while supine.

CTAR Exercise:

• Isometric: While seated, the patient tucks the chin against a 12 cm inflatable rubber ball and holds the position.

• Isokinetic: 30 repetitions of chin tucks against the ball.

Unlike the Shaker, which requires the patient to lie flat, CTAR is performed in a seated position—making it more accessible for patients with mobility, orthopedic, or respiratory limitations.

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What Did the Research Say?

The initial study by Yoon et al. (2014) evaluated CTAR vs. Shaker in 40 healthy participants (ages 21–39) and measured surface electromyography (sEMG) activity.

Key Findings:

• Greater muscle activation in the suprahyoid region during both isometric and isokinetic phases of CTAR.

• CTAR was perceived as less strenuous than the Shaker exercise.

• CTAR showed higher compliance potential, especially for patients unable to tolerate supine exercises.

• Muscle activation during chin tucking was higher than during the release phase—prompting recommendations for a controlled release for added benefit.

The authors concluded that CTAR could achieve similar or superior strengthening effects compared to the Shaker with better patient adherence.

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What We’ve Learned Since 2014

Since that foundational study, research into CTAR has continued—and the results are promising:

2015 – Kraaijenga et al.

• In head and neck cancer patients, CTAR improved:

  • Chin tuck strength

  • Jaw opening strength

  • Anterior tongue strength

  • Suprahyoid muscle volume

  • Maximum mouth opening

2016 – Sze et al.

• CTAR was found to be more targeted and specific to suprahyoid muscle activation than the Shaker.

2017 – Gao & Zhang

• Comparable outcomes between CTAR and Shaker in:

  • Suprahyoid strength

  • Pyriform sinus residue reduction

  • UES opening

2018 – Park et al.

• CTAR improved:

  • Oral cavity control

  • Laryngeal elevation

  • Epiglottic closure

  • Vallecular and pyriform sinus residue

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Why Clinicians Love CTAR

CTAR is not only effective, but also practical:

• Seated position = ideal for frail, elderly, or medically complex patients.

• Minimal equipment = just a small rubber ball.

• Higher compliance = less effort, less discomfort.

• Clear gains = demonstrated muscle and functional improvements.

Patients who struggle with lying flat or who experience discomfort with traditional exercises often find CTAR more tolerable—and are more likely to stick with it.

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Ready to Try CTAR with Your Patients?

If you’re working with patients who need suprahyoid strengthening but struggle with traditional exercises, CTAR might be your go-to tool. It’s evidence-based, accessible, and continues to show strong outcomes across patient populations.

Always ensure exercises are prescribed based on a thorough clinical swallowing evaluation and individualized treatment plan.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.  

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References

1. Yoon W.L., Khoo JKP, Liow SJR. Chin Tuck Against Resistance (CTAR): A New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-Type Exercise. Dysphagia. 2014;29:243–248.

2. Sze WP, Yoon WL, Escoffier N, Liow SJR. Evaluating the training effects of two swallowing rehabilitation therapies using surface electromyography—CTAR and the Shaker. Dysphagia. 2016;31(2):195–205.

3. Gao J, Zhang HJ. CTAR vs. Shaker on dysphagia after cerebral infarction. Eur J Phys Rehabil Med. 2017;53(3):426–432.

4. You LH, Long BY. Shaker vs. CTAR for radiation-induced dysphagia. Chinese J Rehabil Theory Pract. 2017;23(11):1317–1320.

5. Park JS, Lee G, Jung YJ. Game-based CTAR vs. head-lift for post-stroke dysphagia. J Rehabil Med. 2019.

6. Kraaijenga SAC et al. Strengthening exercises in senior healthy subjects. Dysphagia. 2015;30(4):392–403.

7. Park, J. S., & Hwang, N. K. (2021). Chin tuck against resistance exercise for dysphagia rehabilitation: a systematic review. Journal of Oral Rehabilitation, 48(8), 968-977.
8. Liu, J., Wang, Q., Tian, J., Zhou, W., Gao, Y., Chen, X., … & Zhou, L. (2023). Effects of chin tuck against resistance exercise on post-stroke dysphagia rehabilitation: A systematic review and meta-analysis. Frontiers in neurology, 13, 1109140.
9. Zhang, B., Wong, K. P., Guo, C., Chen, S. C., Fu, S., Kang, R., … & Qin, J. (2025). Effects of Non‐Pharmacological Interventions on the Swallowing Function of Patients With Post‐Stroke Dysphagia: A Systematic Review and Network Meta‐Analysis. Journal of oral rehabilitation, 52(1), 109-120.