INTRODUCTION:

A stroke is a medical emergency. It is the second leading cause of death worldwide, and the prevalence of stroke and related deaths is increasing. The estimated adjusted prevalence rate of stroke range, 84-262/100,000 in rural and 334-424/100,000 in urban areas.

Dysphagia presents in approximately 55% of all acute stroke patients admitted to hospital. Among them the or pharyngeal dysphagia, which has an incidence that varies from 40% to 90%, thus becoming a common manifestation of stroke. The presence of dysphagia can itself cause serious consequences like malnutrition, aspiration pneumonia and prone to develop infections. Thus, there is no doubt that the high incidence of dysphagia represents co-factor for mortality and morbidity (Ekberg, 2014).

Dysphagia can adversely impact the quality of life, as well as negatively impact the person's ability to maintain adequate hydration and nutrition. Exercise based dysphasia therapy can improve the functional and physiological changes in feeding performance. Dysphagia affects more than 50% of stroke survivors. Fortunately, the majority of these patients recover swallowing function within 7 days, and only 11-13% remains dysphasic after 6 months. One study reported that 80% of patients with prolonged dysphagia required alternative means of enteral feeding (Logemann et al. 2013).

Chin tuck against resistance (CTAR) exercise is claimed that strengthening the suprahyoid muscles is effective in restoring the oral feeding for patients with dysphagia. Yoon studied the activation of the suprahyoid muscles by administering the shaker exercise and CTAR exercise. In CTAR the patient is seated in an upright position and tucks the chin to compress an inflatable rubber ball. He found CTAR exercise is effective than shaker exercise (Yoon, et al. 2013).

Exercise based dysphagia therapy can improve the functional and physiological changes in feeding performance. Compensatory strategies such as postures, feeding maneuvers, and with rehabilitative exercises like shaker exercise are designed to facilitate a physiologic change in the impaired laryngeal musculature (Park, et al. 2019).

However, there is paucity of research on effectiveness of CTAR exercise in improving feeding performance, therefore this study was aimed to determine the effectiveness of CTAR exercise in the improvement in the feeding performance among the stroke patients.

STATEMENT OF THE PROBLEM:

A Quasi-Experimental Study to Assess the Effectiveness of Chin Tuck Against Resistance Exercise upon Feeding Performance of Patients with Cerebrovascular Accident at Selected Hospital, Chennai.

OBJECTIVES OF THE STUDY:

1. To evaluate the level of feeding performance among control and experimental group of patients with cerebrovascular accident.

2. To determine the effectiveness of chin tuck against resistance exercise upon feeding performance among patients with cerebrovascular accident.

3. To find out the association between selected demographic variables and level of feeding performance in control and experimental group of patients with cerebrovascular accident.

4. To find out the association between selected clinical variables and level of feeding performance in control and experimental group of patients with cerebrovascular accident.

NULL HYPOTHESES:

H01: There will be no significant difference between pretest and posttest feeding performance scores in control and experimental group of patients with cerebrovascular accident.

H02: There will be no significant difference in pretest and posttest feeding performance scores between control and experimental group of patients with cerebrovascular accident.

Ho3: There will be no significant association between selected demographic variables and feeding performance in control and experimental group of patients with cerebrovascular accident

Ho4: There will be no significant association between selected clinical variables and level of feeding performance in control and experimental group of patients with cerebrovascular accident.

METHODS AND MATERIALS:

A quasi-experimental research design was used to conduct the study. The study was conducted in selected two private hospitals in Chennai. After obtaining approval of the Institutional Ethical Committee and setting permission 70 patients with cerebrovascular accident were chosen by using the consecutive sampling technique (35 in control group and 35 in experimental group). After obtaining informed consent, the baseline data was collected using pretested and predetermined tools such as demographic variables proforma, clinical variables proforma and Functional Oral Intake Scale (FOIS), it is a seven-point scale which describes the various components of NG feeding and feeding ability. Main study was conducted after the pilot study to determine the effectiveness of chin tuck against resistance exercise upon feeding performance among patients with cerebrovascular accident.

After initial introduction, the pretest was done for both control and experimental group of patients through structured interview using pretested and predetermined tools. Then the CTAR exercise was administered for 8 consecutive days 3 times a day to the experimental group. Participants were asked to place the inflatable ball with a diameter of 12cm between the chin and the sternum. For the isometric component of the exercise, the ball was com- pressed between chin and sternum at maximum force for 60s. It was repeated 3 times with rest intervals of 60s. For the isotonic component, the participants compressed and relaxed the ball between chin and sternum for 30 times. The exercise set consisted of three isometric and an isotonic component. On 8th day, the posttest on feeding performance was assessed. The collected data were analyzed using descriptive and inferential statistics in SPSS-20 version.

Fig 1: Chin Tuck Against Resistance (CTAR)

RESULTS AND DISCUSSION:

In this study 34.28% and 42.85% of patients with cerebrovascular accident were aged between 51 and 60 years, More than half of them were males (50%, 60.28 %), 34.28% and 40% of them had primary education, Majority of them were married (85.71%, 88.57%), with the family income of < Rs. 30,000 (71.43%, 68.57%) and majority of them were employed in private sector in control group and most of them were business in experimental group respectively.

Figure 2: Percentage distribution of Nature of work among Control and Experimental Group of Patients with Cerebrovascular accident.

Majority of the patients with cerebrovascular accident were on nasogastric tube (65.72%,57.14%), moderate workers (68.57 %,77.14%), performed exercise 3 times per week (45.72%,51.72%) and on anti-diabetic drugs (54.28%,45.72%), hospitalized for above 21 days (54.28%, 60%), had a family history of stroke (60%,45.72%).

With regard to other variables majority of them were current smokers (65.72%, 57.14%), had daily alcohol intake (65.72%, 57.14%), and had co morbid illness (54.28%,45.72%), had ischemic type of stroke (60%, 65.72%) and most of them did not have any previous history of stroke (82.85%, 74.28%) among the control and experimental group of patients with cerebrovascular accident respectively. Most of them were on medical management in control group (80%) and on surgical treatment in experimental group (82.85%).

The study findings on feeding performance of the control group of patients with cerebrovascular accident reveals that 37.14% of them were on NG tube with consistent oral intake in pretest and 42.82% of them were on single consistency diet in posttest. Whereas in experimental group of patients more than half of them were on total NG feed (54.28%) in pretest and (54.28%) of them were on regular diet without any restrictions in posttest.

Table 1 reveals that , there was no statistically significant difference in mean pretest score of feeding performance between control group (M=2.63, S.D+1.12) and experimental group (M=2.05, S.D+1.28) with‘t’ value 1.95 (p>0.05). Whereas, there was a significant difference in the mean posttest scores of feeding performance between the control group (M=3.13, S . D +1.23) and experimental group (M=6.4, S.D+0.72) with‘t’ value of 18.22, which was statistically significant at p<0.001.Hence the null hypothesis Ho2 “there will be no significant difference in feeding performance scores in pretest and posttest between control and experimental group of patients with cerebrovascular accident” was rejected.

There was a significant difference in the feeding performance scores between pretest (M= 2.63, S. D+1.12) and posttest (M=3.13, S. D+1.23) with a ‘t’ value of 6.35 at P<0.001 in control group. In experimental group also there was a significant difference in feeding performance between pretest (M=2.05, S. D+1.28) and posttest (M=6.4, SD+1.72) with a ‘t’ value of 24.34 at P<0.001. Hence the null hypothesis Ho1“there will be no significant difference in feeding performance scores between pretest and posttest in control and experimental group of patients with cerebrovascular accident” was rejected.

The findings of the study were consistent with that of a quasi-experimental research study conducted by Priya, (2018) on the effectiveness of chin tuck against resistance exercise in improving feeding performance among cerebrovascular accident patients with dysphagia among 32 samples. Intervention group, the pretest assessment shows that the patients were having severe dysphagia with the mean score of (4.38±0.48) before administering CTAR exercise. The calculated’ value is 17.347 which is greater than the table value (4.073) at the level of p<0.001. This indicates that there is a significant difference between the pretest and the post test scores of among CVA patients who received CTAR exercise. There was a remarkable progress in the mean CTAR score from day 1(4.38±0.48) to day 8 (16.31± 3.16).

There was no significant association between feeding performance and demographic variables like age, gender and type of work in control and experimental group. Hence the null Ho3 There will be no significant association between selected demographic variables and feeding performance in control and experimental group of patients with cerebrovascular accident was retained.

There was also no significant association between clinical variables like current ^{diet, co morbid condition and type of
stroke. However, there was a significant association between the feeding
performance and clinical variable frequency of exercise among control group of
patients (x2=13.20, df=1) at p<0.05 level. However, there was no significant
association between other clinical variables like current diet, co morbid
condition and type of stroke}in control and experimental group of patients with cerebrovascular accident.^{In this regard, the null hypothesis}H04“there will be no significant association between the selected clinical variables and level of feeding performance among the control group of patients with cerebrovascular accident” was rejected with respect to frequency of exercise.

CONCLUSION:

The present study findings revealed that, chin tuck against resistance exercise is effective in improving feeding performance and the wellbeing of patient with cerebrovascular accident.

REFERENCES:

1. Ekberg, O. (2014). Defective closure of the laryngeal vestibule during deglutition. Journal of Acta Otolaryngology, Mar-Apr; 93 (3-4):309-17.

2. Logemann, J.A., Rademaker, A., Pauloski, B.R., Kelly, A., Stangl-McBreen, C., Antinoja, J., Grande, B., Frquharson, J., Kern, M., Easterling, C., & Shaker, R. (2013). A randomized study comparing the Shaker exercise with traditional therapy: A preliminary study. Journal of Speech Language Hearing Research 24:403-411.

3. Yoon, W. L., Khoo, J. K. P., Rickard Liow, S. J. (2013). Chin Tuck Against Resistance (CTAR): New method for enhancing suprahyoid muscle activity using a Shaker-type Exercise. Journal of Dysphagia, 29(2), 243-248. doi: 10.1007/s00455-013-9502-9

4. 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, 51(10), 749-754.

5. Johnson, D.N., Herring, H.J.& Daniels, S.K. (2014). Dysphagia management in stroke rehabilitation. Current Physical Medicine and Rehabilitation Report, 2:207-218

6. Kim, H. H., & Park, J. S. (2019). Efficacy of modified chin tuck against resistance exercise using hand‐free device for dysphagia in stroke survivors: A randomised controlled trial. Journal of Oral Rehabilitation, 46(11), 1042-1046.

7. SanthoshPriya, N. (2017). A study to assess the effectiveness of Chin Tuck Against Resistance (CTAR) exercise in improving swallowing ability among Cerebrovascular accident patients with dysphagia at selected hospital, Coimbatore (Doctoral dissertation, PSG College of Nursing, Coimbatore).

8. Sze, W.P., Yoon,W.L.,Escoffier, N., &Liow,S.J.R.(2013). Evaluating the training effects of two swallowing rehabilitation therapies using surface electromyography Chin tuck against resistance (CTAR) xerciseandtheShakerexercise.Dysphagia,31(2),195-205.

Received on 23.04.2022 Modified on 07.05.2022

Int. J. Nur. Edu. and Research. 2022; 10(3):235-238.

DOI: 10.52711/2454-2660.2022.00055

Variables	Control Group (n=35)		Experimental Group (n=35)			Independent ‘t’ value & P Value
Variables	Mean	SD	Mean	SD	Mean Difference	Independent ‘t’ value & P Value
Feeding Performance
Pretest	2.63	1.12	2.05	1.28	0.58	1.95
Post test	3.15	1.23	6.4	0.72	3.25	18.22
Paired ‘t’ test and P Value	6.35		24.34			P< 0.001

Table 1: Comparison of Pretest and Posttest Feeding Performance Scores among Patients with Cerebrovascular Accident between Control and Experimental Group.