A huge thanks to Jolie Parker for sending me an ISO device for this blog post!!

I am always trying to find an exercise that is fairly easy for my patients.  A great exercise is the Shaker.  The guidelines for repetitions are provided!  Not many exercises come with instructions for reps.  The Shaker focuses on the suprahyoid muscles and assists with UES opening, reducing pyriform sinus residue.

The problem with the Shaker is that it is very difficult to complete.

One thing I do know about exercise is that by adding resistance, you are adding “weight” to the exercise.  Now, most people don’t run to the gym to lift “air weights”.  They left weights and then add to the weight to increase muscle and strength.

I recently wrote a post about an article for CTAR or Chin Tuck Against Resistance.  Another great article to read is about an exercise called Jaw Opening Against Resistance.  CTAR is very similar to the Shaker, however the patient remains seated upright and use a device for the resistance.

Initially, I used the Neckline Slimmer as resistance.  The Neckline Slimmer is a tiny little device with a spring inside.  You push down using your chin on the top until you can no longer push.  The bottom portion of the device is on your chest so you are doing a chin tuck.  The spring offers resistance.  The spring is also interchangable and comes in low, medium and high resistance.

Neckline Slimmer

The trouble with the Neckline Slimmer, which was created to help people eliminate a double chin, doesn’t last as long as I long as I would like it to last.  It also can be a little painful for my elderly patients, who are very thin especially.   The plate that rests against the chest often hurt the patient.

Now, if you are on Facebook and “like” anything dysphagia-related, you have probably seen the ISO device.  This is a device created for the CTAR and JOAR exercises!  It is a larger device with padding on both the chest piece and the chin piece.  The device is made from a flexible polycarbonate and is easy to hold and to use.


A video demonstrating use of the ISO Swallowing Exercise Device (ISO SED) can be viewed here.

The ISO SED can be purchased for $99, however can be used with multiple patients as it has chin pad covers.  The ISO was used with considerably more ease than the Neckline Slimmer, is more durable and less painful.

If you are interested in checking out the ISO SED, you can find more information here.

Clark, H.M. (2005).  Therapeutic exercise in dysphagia management:  Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

Burkhead L.M., Sapienza C.M., Rosenbek J.C. (2007).  Strength training exercise in dysphagia rehabilitation:  Principles, procedures and directions for future research.  Dysphagia; 22:  251-265.

Clark, Heather M. “Neuromuscular Treatments for Speech and SwallowingA Tutorial.” American Journal of Speech-Language Pathology 12.4 (2003): 400-415.

Wada, Satoko, et al. “Jaw-opening exercise for insufficient opening of upper esophageal sphincter.” Archives of physical medicine and rehabilitation 93.11 (2012): 1995-1999.

Yoon, Wai Lam, Jason Kai Peng Khoo, and Susan J. Rickard Liow. “Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise.” Dysphagia 29.2 (2014): 243-248.

CTAR (Chin Tuck Against Resistance)

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

I was beyond excited to pick up my newest edition of the Dysphagia journal. I’ve never said I wasn’t a nerd. There was an article in the journal about chin tuck against resistance. I’ve always used what I call Modified Shaker exercises. My patients are generally elderly. Most have heart conditions or COPD. They are unable to do the Shaker as it was intended.
Most of my patients either use the Neckline Slimmer (available on Amazon) which offers 3 different levels of resistance through springs. They complete exercises exactly as if they were completing the Shaker, but don’t have to lie on the floor and struggle to get up.

This article looked at using Chin Tuck Against Resistance (what I would call a Modified Shaker) to improve activation of the suprahyoids.

Look at patients with dysphagia from Pharyngoesophageal Segment (PES) dysfunction, we look at strengthening the suprahyoid muscles. These muscles assist in hyolaryngeal excursion and therefore play a part in esophageal opening.

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion fo the Shaker is holding the head up for 1 minute with a minute rest x 3 repetitions. The difference is, with CTAR, the patient is holding a 12 cm inflatable rubber ball and performing a chin tuck against it while seated. The Shaker the patient is lying flat on the floor and lifting their head only as if they were looking at their toes.

The isokinetic portion is 30 repetitions of up and down head movement 3 times.

This study used 40 healthy individuals (20 male, 20 female) 21-39 years of age. All participants completed the Shaker and CTAR both isometric and isokinetic as indicated above. Data was collected over one session.

What the researchers found:

CTAR:  The Chin Tuck Against Resistance was less strenuous than the traditional Shaker, with increased sEMG values during isometric and isokinetic movement. There was a significant increase for the isometric portion of the exercise. These patient had greater muscle activation using the rubber ball and a chin tuck!

Effort was required for the chin tuck, but not for the release.  The authors felt is might benefit to have the patient release compression of the ball slowly.

There was greater muscle activation for the isokinetic movement than for the isometric movement during the traditional Shaker. The Shaker also yielded considerable greater effort to lower the head to the mat.

“Clinical trials are now needed, but the CTAR exercises appear effective in exercising the suprahyoid muscles and could achieve therapeutic effects comparable to those of Shaker exercises, with the potential for greater compliance by patients.”

Overall, CTAR was an effective in exercising suprahyoid muscles in healthy participants.

This looks promising in giving us an alternative for our patients for the Shaker exercise!!