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CTAR (Chin Tuck Against Resistance)

Way back in 2014……

Way back in 2014, an article was published describing Chin Tuck Against Resistance.

When we 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.

Isokinetic vs. Isometric

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion of 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. When performing 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.”

The Results

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!!

Since the initial study.

There have been several studies since the initial CTAR study in 2014.  What are the results of these newer studies you might ask?

Well……

In 2015, head and neck patients that completed CTAR had increased:

  • chin tuck strength
  • jaw opening strength
  • anterior tongue strength
  • suprahyoid muscle volume
  • maximum mouth opening

In 2016, it was found that CTAR is more specific in targeting the suprahyoid muscles than the Shaker.

In 2017, it was found that there is the same benefits from completing CTAR as there is in completing the Shaker (increased suprahyoid strength, decreased pyriform sinus residue due to increased esophageal opening).

In 2018, Park, et al found improvements in:

  • oral cavity
  • laryngeal elevation
  • epiglottic closure
  • vallecular residue
  • pyriform residue

CTAR with your patients.

I think we can all agree, CTAR is by far much easier on our patients than the Shaker.   Many struggle when lying flat on their backs and struggle to lift their head and maintain the hold.   When the exercise does not impede respiration and is easier to complete, we do see greater compliance.

References:

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.

Sze, W. P., Yoon, W. L., Escoffier, N., & Liow, S. J. R. (2016). Evaluating the training effects of two swallowing rehabilitation therapies using surface electromyography—Chin tuck against resistance (CTAR) exercise and the Shaker exercise. Dysphagia, 31(2), 195-205.

Gao, J., & Zhang, H. J. (2017). Effects of chin tuck against resistance exercise versus Shaker exercise on dysphagia and psychological state after cerebral infarction. European journal of physical and rehabilitation medicine53(3), 426-432.

You, L. H., & Long, B. Y. (2017). Comparison of Shaker Exercise and Chin Tuck Against Resistance Exercise for Radiation-induced Dysphagia af-ter Nasopharyngeal Carcinoma. Chinese Journal of Rehabilitation Theory and Practice23(11), 1317-1320.

Park, J. S., Lee, G., & Jung, Y. J. (2019). Effects of game-based chin-tuck against resistance exercise vs head-lift exercise in patients with dysphagia after stroke: An assessor-blind, randomized controlled trial. Journal of rehabilitation medicine.

Kraaijenga, S. A. C., Van Der Molen, L., Stuiver, M. M., Teertstra, H. J., Hilgers, F. J. M., & van Den Brekel, M. W. M. (2015). Effects of strengthening exercises on swallowing musculature and function in senior healthy subjects: a prospective effectiveness and feasibility study. Dysphagia30(4), 392-403.

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Pudding and a Straw

                                                                                

Picture from: http://www.busymomboutique.com

Looking for an exercise.

Haven’t you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

What’s it called?

This exercise has no fancy name.  I call it……..Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

What does the evidence tell us?

So first, let’s look at the evidence…….  I take into account that, from reading research…..I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow because of the sensory input from the heavier bolus.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.  There is an increased benefit in cuing the patient to swallow the entire bolus as hard and fast as possible.  

Putting it all together

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It’s great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

It’s difficult to target one portion of the swallow when actually working with swallowing.   This is where the Home Exercise Program (HEP) can be beneficial in targeting a specific muscle/muscle group when necessary.   This doesn’t mean the saying k/g words 1 million times a day.  This means evidence-based functional exercises.

Where to begin.

Keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I’ve found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Viscosity of the bolus.

The viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I’m also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

What is the goal, you might ask.

I don’t write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don’t write my notes as “the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding.”  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

Keep your cool.

I don’t stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

A challenge

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

References:

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

 

Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

 

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, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial.

 

Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

 

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

 

Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

 

Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

 

Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

 

Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.