INTRODUCTION:

Swallowing issues that arise in the pharynx or oral cavity are known as dysphagia. Structural changes influencing food bolus movement may be the cause of dysphagia, which affects the effectiveness and safety of the swallowing function.^1,2Dysphagia is prevalent among older adults, affecting 25% of those living independently and over 50% in nursing homes. It primarily results from reduced bolus propulsion due to tongue sarcopenia, with compromised swallow response contributing to oropharyngeal aspiration.

This condition leads to malnutrition, dehydration, reduced quality of life, respiratory infections, aspiration pneumonia, and poorer prognoses, including longer hospital stays and increased morbidity and mortality across various older patient groups.^3,4

Chin tuck against resistance (CTAR) exercise has recently been identified as a new therapeutic exercise strategy that can aid improve swallowing function in dysphagia patients. The Chin Tuck Against Resistance (CTAR) exercise originated to replace the popular Shaker exercise in dysphagia therapy. The effectiveness of CTAR exercise in stroke survivors needs to be tested. As a result, the researcher chose this specific research initiative.^5,6,7

The chin tuck against resistance (CTAR) exercise was first reported by Yoon et al. The authors compared the surface electromyography (sEMG) activity of the suprahyoid muscles during the Chin Tuck Against Resistance (CTAR) and Shaker exercises in 40 participants aged 21-39. The study found that CTAR resulted in significantly higher maximum and mean sEMG values compared to Shaker exercises. Although participants perceived CTAR as less strenuous, it was concluded that CTAR effectively trains suprahyoid muscles and may enhance patient compliance similarly to Shaker exercises.^8,9

Jing Liu et al. (2023), Conducted a systematic review of nine studies with 548 participants, it was found that Chin tuck against resistance (CTAR) exercise significantly improves swallowing function and psychological well-being in stroke survivors. CTAR showed better swallowing safety and oral intake ability compared to no exercise and outperformed Shaker exercise in these areas. The authors concluded that CTAR is a superior intervention for post-stroke dysphagia rehabilitation and recommended further randomized controlled trials to examine its effects on various stroke types and optimal training dosages.¹⁰

The current study sought to assess the effect of the CTAR exercise on swallowing function in persons with dysphagia (Experimental Group) by combining it with standard medical treatment (Control Group) and comparing the findings.

MATERIALS AND METHODS:

This quasi-experimental study at VIMS Hospital in Salem involved 60 participants, divided into 30 in the experimental group and 30 in the control group, all of whom provided informed consent. Data on demographics and medical history were collected via interviews and medical records. The study assessed swallowing ability in CVA patients using the Gugging Swallowing Screen, with the experimental group performing the Chin Tuck Against Resistance (CTAR) exercise three times a day for eight days, while the control group received routine care. A posttest using GUSS was conducted to evaluate swallowing ability for both groups after the exercise period.

CTAR Protocol:

CTAR exercise is an activity performed with a 12 cm diameter inflatable rubber ball which is placed between chin and base of neck to provide resistance when the patient is seated in upright position, chin tuck against the ball and sustained it for 10 sec (isometric) and for 10 repetitions (iso Kinetic) Three times a day for and consecutive day.

Data Collection tool:

The Gugging Swallowing Screen scale (GUSS), developed by Trapl M and Michael Brainin in 2007 at the Danube University in Austria, is designed to assess patients' swallowing abilities with tested reliability of 0.9. It includes a two-part assessment: Part 1 is an indirect swallowing test, and Part 2 comprises three sequential subtests for assessing swallowing of semisolid, liquid, and solid diets. Mild dysphagia ranges from 10 to 14, moderate dysphagia from 15 to 19, and severe dysphagia from 0 to 9.

RESULTS:

Table 1. Frequency and percentage distribution of pretest and posttest level of swallowing, before and after chin tuck against resistance (CTAR) exercise among cerebrovascular accident patients with dysphagia in experimental group and control group

(N=60)

Level of Dysphagia		Mild		Moderate		Severe
Level of Dysphagia		f	%	f	%	f	%
Control group	Pretest			16	53	14	47
Control group	Post test			17	57	13	43
Experimental group	Pretest			15	50	15	50
Experimental group	Post test	8	27	16	53	6	20

The table shows the pre- and post-test scores for dysphagia severity in both the control and experimental groups. There were no significant changes in the control group, with 47% having severe dysphagia prior to the test and 57% still having moderate dysphagia after the test. In contrast, the experimental group exhibited improvement after intervention: the initial equal distributions of severe and moderate dysphagia shifted to 20% severe, 53% moderate, and 27% mild dysphagia, showing a significant increase in swallowing ability.

Table 2. mean, SD, Paired and Unpaired values of pre and posttest swallowing scores before and after chin tuck against resistance (CTAR) exercise among cerebrovascular accident patients with dysphagia in experimental group and control group (N=60)

Level of Dysphagia		Mean±SD	Paired t test	Unpaired t test – Post test
Control group	Pre test	3.36±0.8	CV - 0.146 for df 29 P value is more than 0.5	16.56 for df 58 P value is less than 0.001
	Post Test	3.39±0.79
Experimental group	Pre test	3.42±0.81	CV- 16.47 for df 29 P value is less than 0.001
	Post Test	12.1±2.77

The table shows mean, SD, paired and unpaired t values for dysphagia severity between pretest and posttest and also between control and experimental groups. The result reveal that, the calculated paired t value for control group pre and posttest was 0.146 for df 29 which is less than the table value 1.699(p<0.05). This difference is considered to be not statistically significant. In contrast to this calculated paired t value in experimental group was 16.47 for df 29, which is more than the table value 1.699(p>0.001). This difference is considered to be extremely statistically significant.

The calculated unpaired t test vale for the post test scores between control and experimental group was 16.56 for df 58. The P vale was less than 0.001. This clearly shows that the administration of chin tuck against resistance (CTAR) exercise had improving swallowing ability among cerebrovascular accident patients with dysphagia.

CONCLUSION:

This study assessed the effect of the Chin Tuck Against Resistance (CTAR) exercise on the swallowing function of cerebrovascular accident (CVA) patients suffering from dysphagia. The quasi-experimental findings demonstrate that the CTAR exercise protocol significantly improves swallowing abilities among this demographic. Participants in the experimental group showed a notable increase in GUSS scores after an eight-day CTAR regimen, with many transitioning from severe and moderate dysphagia to primarily mild and moderate levels. Statistically, this improvement is significant, evidenced by a high mean GUSS score increase and paired t-test results (p<0.001). In contrast, the control group, which only received routine care, showed no significant change in dysphagia status. The stark difference in post-test scores (p<0.001) further emphasizes the effectiveness of CTAR as a targeted intervention. These results are consistent with findings from previous studies by Jing Liu et al. (2023) and Yoon et al. (2014), which reported better muscle activation and clinical outcomes with CTAR compared to traditional exercises like the Shaker exercise. Consequently, strengthening the suprahyoid muscles through CTAR emerges as an effective and non-invasive treatment strategy for post-stroke dysphagia.

RECOMMENDATIONS:

Although the study effectively illustrates the short-term efficacy of CTAR, its small sample size and brief duration limit its applicability. To further investigate the long-term effects, ideal training dosages, and applicability across various stroke types and severities, future research should incorporate bigger, multi-center randomized controlled studies. However, in order to improve swallowing function, lower comorbidities, and improve overall quality of life, our study recommends incorporating the CTAR exercise into normal rehabilitation regimens for CVA patients with dysphagia.

REFERENCES:

1. Park, J. S., and Hwang, N. K. Chin tuck against resistance exercise for dysphagia rehabilitation: a systematic review. Journal of Oral Rehabilitation. 2021; 48(8): 968-977.

2. Rofes, L., Arreola, V., Almirall, J., Cabré, M., Campins, L., García-Peris, P., and Clavé, P. Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology research and Practice. 2011; 1: 818979.

3. Clavé, P., Rofes, L., Carrión, S., Ortega, O., Cabré, M., Serra-Prat, M., and Arreola, V. Pathophysiology, relevance and natural history of oropharyngeal dysphagia among older people. In Nestle Nutr Inst Workshop Ser. 2012; 72(1): 57-66.

4. Wirth, R., Dziewas, R., Beck, A. M., Clave, P., Hamdy, S., Heppner, H. J., and Volkert, D. Oropharyngeal dysphagia in older persons–from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clinical intervEntions in Aging. 2016; 189-208.

5. Park, J. S., and Hwang, N. K. Chin tuck against resistance exercise for dysphagia rehabilitation: a systematic review. Journal of Oral Rehabilitation. 2021; 48(8): 968-977.

6. Wirth, R., Dziewas, R., Beck, A. M., Clave, P., Hamdy, S., Heppner, H. J., and Volkert, D. Oropharyngeal dysphagia in older persons–from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clinical Interventions in Aging. 2016: 189-208.

7. Jones, E., Speyer, R., Kertscher, B., Denman, D., Swan, K., and Cordier, R. Health-related quality of life and oropharyngeal dysphagia: a systematic review. Dysphagia, 2018; 33(2): 141-172.

8. Yoon, W. L., Khoo, J. K. P., and Rickard Liow, S. J. Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia. 2014; 29(2): 243-248.

9. Melgaard, D., Baandrup, U., Bøgsted, M., Bendtsen, M. D., and Hansen, T. The prevalence of oropharyngeal dysphagia in Danish patients hospitalised with community-acquired pneumonia. Dysphagia. 2017; 32(3): 383-392.

10. Liu, J., Wang, Q., Tian, J., Zhou, W., Gao, Y., Chen, X., and Zhou, L. Effects of chin tuck against resistance exercise on post-stroke dysphagia rehabilitation: A systematic review and meta-analysis. Frontiers in Neurology. 2023; 13: 1109140.

Received on 25.11.2025 Revised on 03.01.2026

Accepted on 01.02.2026 Published on 30.07.2026

Available online from August 05, 2026

Int. J. Nursing Education and Research. 2026;14(3):232-234.

DOI: 10.52711/2454-2660.2026.00046

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