swallowing therapy

Latihan Menelan (Dysphagia Therapy) Chin Tuck Against Resistance / CTAR dengan Bola Getah

Video latihan menelan Chin Tuck Against Resistance / CTAR
GDM would like to express our heartfelt thanks to Ms Siti Amirah for her help in translation of the Malay Version of the CTAR video.

Video latihan menelan Chin Tuck Against Resistance / CTAR ini merupakan video Bahasa Melayu pertama yang dihasilkan oleh Singapore Swallowing Specialists.

Chin Tuck Against Resistance (CTAR) dengan Bola Getah

Tujuan: Untuk menguatkan otot suprahyoid yang digunakan semasa menelan. Otot-otot suprahyoid penting untuk membuka sfinkter paip makanan atas anda (sfinkter esofagus atas) untuk membolehkan makanan memasuki perut anda.

 Peralatan: 1) Bola getah, 2) jarum pam udara dan pam udara (pilihan) – untuk meningkatkan diameter dan tekanan bola


 Bahagian 1: CTAR berkekalan (Isometrik)

  • Duduk / berdiri tegak dan tarik bahu ke belakang.  Kekalkan postur ini semasa latihan.
  • Pegang bola di bawah dagu dengan tangan anda dan kekalkan posisi bola sepanjang latihan.
  • Tundukkan dagu anda pada bola sekeras mungkin; dan kekalkan  selama _______ saat.
  • Ulangi _______ set seperti yang disyorkan oleh terapis / patologis pertuturan anda.
  • Rehat selama 1 minit di antara setiap set latihan.

 Bahagian 2: CTAR berulang (Isokinetik)

  • Duduk / berdiri tegak dan tarik bahu ke belakang.  Kekalkan postur ini semasa latihan.
  • Pegang bola di bawah dagu dengan tangan anda dan kekalkan posisi bola sepanjang latihan.
  • Tundukkan dagu anda, sekeras mungkin pada bola;  kemudian angkat dagu.
  • Ulangi langkah di atas untuk ________ kali dan set ________ seperti yang disyorkan oleh terapis / patologis pertuturan anda.
  • Rehat selama 1 minit di antara setiap set latihan.

Klik pada yang berikut untuk memuat turun (download) arahan latihan:

CTAR with Rubber Ball Exercise videos are available in the following languages:

* Click to view CTAR videos in the following languages.

Chin Tuck Against Resistance (CTAR) exercise is suitable for most patients with swallowing difficulties / dysphagia:

  • dysphagia or swallowing difficulties following strokes,
  • dysphagia following head and neck cancer,
  • dysphagia following Parkinson’s disease,
  • dysphagia due to late effect of radiotherapy i.e. Nasopharyngeal cancer
  • etc.
dysphagia research

Swallow with CTAR (S-CTAR) Poster presented at DRS 2017 @ Portland, Oregon

S-CTAR Poster

Life has been so busy since I came back from DRS 2017. Finally, I have some time to put up this blog.

I was honored to be invited to present a research poster at DRS this year.

This is probably one of the best year for dysphagia research representation from Singapore as we have 2 oral presentations from Singapore General Hospital and 1 poster presentation (presented by me) from National University of Singapore.

My poster presentation was on Swallow with Chin Tuck Against Resistance (S-CTAR). 

Some of the happy moments at DRS:

  • Portland, Oregon is really beautiful and … cold. 
  • Finally get a chance to meet my Facebook pal, Nabil from Canada in person. We share a common interest in dysphagia. Lots of interesting discussion on dysphagia via WhatsApp and Facebook messenger. 
  • Get to meet some old friends and made more new friends from all around the world. 
  • managed to take a selfie with Dr Reza Shaker!
  • Happy to know that CTAR or Chin Tuck Against Resistance is a well known and well like exercise in USA and Brazil. Brazil Speech Pathologists informed me that they have started research on CTAR! I really hope that clinical study on CTAR will be out soon. 
  • Most Speech-Language Pathologists were excited to know that S-CTAR can be used as a task specific exercise and foresee that they will use it in their dysphagia therapy or management. 
Portland Oregon
Portland, Oregon
Portland, Oregon
  • With Dr Shaker
    with Dr Reza Shaker
    Nabil = my FB Pal
    My FB Pal, SLP from Canada – Nabil
    Kotomi - SLP from Japan
    Kotomi Sakai – SLP from Japan
    Brazil SLP
    SLP from Brazil
    Poster presentation
    Demonstrating CTAR to a dentist from Japan
    Demonstrating CTAR & S-CTAR
    Demonstrating CTAR and S-CTAR
    I am a new DRS Member
    I am a new DRS member.
    Ironing sandwich
    This is new to me… Ironing sandwiches?!!!

    I was asked a few interesting questions on CTAR. One of the few interesting question is: are there any devices in the market that you think is good to be used to perform CTAR? I think this is an interesting question as we have seen quite a number of devices (different type of balls, hand held devices etc) being introduced to the market since the first paper on CTAR was published in 2014.

    Click  S-CTAR Poster to download the poster that I presented at DRS 2017.

    I will list out all those questions and answers in separate post soon. 

    To end this post, I would like to congratulate and express my appreciation to all the DRS committees for this successful and enlightening meeting. 

    Swallowing Problem

    How does dysphagia from mechanical obstruction sounds like?

    The following patient presents with dysphagia (swallowing difficulties) secondary to the presence of prominent anterior cervical osteophytes at the level of C3-C6, most prominent at C4.

    Dysphagia symptoms include:

    • Occasional coughing noted when eating solids as well as drinking fluids.
    • Multiple swallows per bolus

    I managed to record the patient’s usual swallowing sound using my IPhone 6s. Could this be the sound of mechanical obstruction?

    MRI Cervical Spine shows cervical myelopathy. Prominent anterior cervical osteophytes from C3-C6.
    osteophytes label

    The sound of patient swallowing 10ml water recorded using an IPhone 6s. Note multiple swallows & loud squish sound.

    Cost effective treatment, dysphagia research, Dysphagia Therapy, Singapore, speech therapy singapore, speech-language therapy, Swallowing Problem, Teaching, Uncategorized

    Second Publication on Chin Tuck Against Resistance (CTAR)

    We are happy to announce that the follow up study on CTAR has been published online (online first version) in Dysphagia Journal.

    Original Paper


    pp 1-11

    First online: 02 February 2016

    Evaluating the Training Effects of Two Swallowing Rehabilitation Therapies Using Surface Electromyography—Chin Tuck Against Resistance (CTAR) Exercise and the Shaker Exercise

    • Wei Ping Sze 
    • , Wai Lam Yoon
    • , Nicolas Escoffier
    • , Susan J. Rickard Liow


    In this study, the efficacy of two dysphagia interventions, the Chin Tuck against Resistance (CTAR) and Shaker exercises, were evaluated based on two principles in exercise science—muscle-specificity and training intensity. Both exercises were developed to strengthen the suprahyoid muscles, whose contractions facilitate the opening of the upper esophageal sphincter, thereby improving bolus transfer. Thirty-nine healthy adults performed two trials of both exercises in counter-balanced order. Surface electromyography (sEMG) recordings were simultaneously collected from suprahyoid muscle group and sternocleidomastoid muscle during the exercises. Converging results using sEMG amplitude analyses suggested that the CTAR was more specific in targeting the suprahyoid muscles than the Shaker exercise. Fatigue analyses on sEMG signals further indicated that the suprahyoid muscle group were equally or significantly fatigued (depending on metric), when participants carried out CTAR compared to the Shaker exercise. Importantly, unlike during Shaker exercise, the sternocleidomastoid muscles were significantly less activated and fatigued during CTAR. Lowering the chin against resistance is therefore sufficiently specific and intense to fatigue the suprahyoid muscles.

    Details of the journal can be found at http://link.springer.com/article/10.1007%2Fs00455-015-9678-2

    We are happy to announce that we are starting our third CTAR research at the National University of Singapore.

    CTAR research 3
    CTAR research 3 in progress

    materials for CTAR 3
    Materials used in CTAR 3

    Dysphagia Therapy, Featured clinicians, Singapore, Swallowing Problem, Teaching, Uncategorized

    Workshop on ‘Best Practices in the Management of Oropharyngeal Dysphagia’

    Dear all,

    JurongHealth Speech Therapy department will be organising a 2 day workshop next year entitled ‘Best Practices in the Management of Oropharyngeal Dysphagia’. The workshop will be conducted by Dr. Catriona Steele and will be held on 20 – 21 May, 2016 at Ng Teng Fong General Hospital, Singapore.



    About the speaker:

    Dr. Catriona M. Steele is a clinician scientist working in the area of swallowing and swallowing disorders. She has a background as a medical speech-language pathologist, and is Director of the Swallowing Rehabilitation Research Laboratory at the Toronto Rehabilitation Institute – University Health Network. Dr. Steele is a Professor in the Department of Speech-Language Pathology at the University of Toronto and is in demand as a teacher and workshop instructor around the world. Dr. Steele holds research funding from the National Institutes of Health (USA) and has more than 100 peer-reviewed publications.


    Brief outline of workshop

    > Best Practices in the Identification and Assessment of Oropharyngeal Dysphagia

    –   Sensitivity and specificity of different dysphagia screening tools

    –   Purpose, protocols and important technical considerations of videofluoroscopy

    – Using information from research to quantify observations during a clinical bedside swallowing assessment

    > Management and Rehabilitation of Oropharyngeal Dysphagia

    –  Evidence behind texture modification and postural approaches

    –  Direct and indirect swallowing/exercise approaches including the use of IOPI and sEMG biofeedback

    –  Other approaches in the literature: respiratory interventions, electrical stimulation, vibratory stimulation


    Estimated cost:  $400 – $500 per participant for the full workshop.



    Registration Correspondent: Ms Wong Wan Xin

    Wong Wan Xin| Speech Therapist, Rehabilitation | Ng Teng Fong General Hospital & Jurong Community Hospital | Jurong Health Services
    1 Jurong East Street 21, Singapore 609606 | T: (65) 67161674 | E: Wan_Xin_Wong@juronghealth.com.sg

    Cost effective treatment, Dysphagia Therapy, speech therapy singapore, speech-language therapy, Teaching

    Beckman Oral Motor Assessment and Intervention © Course

    beckman OM

    About the Workshop:

    Oral motor impairment presents a variety of challenges for both the individual affected, and for the care team providing intervention. Often the individual experiencing oral motor difficulties is not able to follow commands. The person may not be eating or taking fluids orally, which reduces the opportunities for observation of oral movement patterns. The majority of baseline protocols currently available require at least minimal direction-following skills. The protocol developed by Beckman uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue. In this two day course, participants will actively participate in hands-on practice for compensatory handling techniques for the following concerns: tonic bite, tonic bite on a utensil, slow oral transit, tongue thrust, cough, gag and vomit. The participants will complete an oral motor protocol with each other, analyze the results, and discuss data tracking. The participants will also complete hands-on practice for specific oral motor interventions to address the deficit areas discovered during baseline assessment. Additional topics of discussion may include: goal writing, diet texture progression, tube to oral issues, adaptive mealtime utensils, oral hygiene issues, medication administration issues, oral function for individuals with tracheotomy, facilitating improved articulation through oral motor techniques, research issues, videofluroscopy issues for motorically involved individuals.

    Speaker: Mr Stephen Chan (Occupational Therapist)

    Target Participants: Licensed Occupational Therapists AND Speech and Language Pathologists/Speech Therapists

    Date &Time:  9th & 10th March, 2016 (Wed & Thur) 9:30am – 5:30pm

    Venue: Room 706, Peninsula Tower, No. 538, Castle Peak Road, Kowloon, HONG KONG

    Seat Availability: 30 seats

    Course Fee:

    • Early Bird registration by 9th January, 2016: HK$4,000 (including course materials)
    • Standard registration by 9th February, 2016: HK$4,500 (including course materials)

    Certification: Upon 100% attendance, participants are awarded the Certificate of Completion by Beckman & Associates, Inc. And after the completion of the course, participants’ name can be listed (optional) on the website http://www.beckmanoralmotor.com.

    Enquiry: To learn more about the course, please visit the website: http://www.beckmanoralmotor.com

    Registration form can be downloaded from: http://www.crest.hk/wp-content/uploads/2014/07/Beckman-Certificate-Course-Information-by-CREST-2016.03-revised.pdf

    For any enquiries, please feel free to contact Mr. Stephen Chan at stephen@crest.hk or (852) 3628 3443

    dysphagia assessment, Dysphagia Therapy, SHAS, speech therapy singapore, speech-language therapy, Swallowing Problem

    SHAS SIG : Sharing on Paediatric Feeding Services Available in Singapore

    Host: Speech-Language and Hearing Association Singapore (SHAS)

    The SHAS will be holding a Special Interest Group : Sharing on Paediatric Feeding Services Available in Singapore

    Date: 26 November 2015 (Thursday).

    Venue: KK Women’s and Children’s Hospital, Women’s Tower (Level 1), Seminar Room 1, 100 Bukit Timah Rd, Singapore 229899

    There will be sharing session by various representatives from different organisations:

    • Cerebral Palsy Alliance Singapore
    • KK Women’s & Children’s Hospital
    • National University Hospital
    • Rainbow Centre
    • Thomson Paediatric Centre

    SHAS paediatric feeding
    If you are interested in attending the session, please email the completed registration form to pd.shas@gmail.com by 20 November 2015 (Friday). 

    Dysphagia Therapy, speech therapy singapore, speech-language therapy, Swallowing Problem

    Workshop on Dysphagia Management: NMES / sEMG Guardian Way in Hong Kong

    Guardian Way Workshop

    Workshop on Dysphagia Management: NMES / sEMG Guardian Way

    Instructors: Teresa Biber, M.S., CCC-SLP

    Nancy Calamusa, MA, CCC-SLP

    Date: 26-27 September 2015 (NMES / sEMG Guardian Way)

    Date: 28 September 2015 (Paediatric Workshop)

    Venue: Kowloon Bay International Trade and Exhibition Centre (KITEC) Room 631, Hong Kong

    Contact:  GSBE Company Ltd at 9190-0180 or or GSBECOMPANYLTD@GMAIL.COM

    Co-organizer: SpectraMed, Inc. and GSBE Company Ltd

    Please refer to attached registration forms for details.




    Dysphagia Therapy, speech therapy singapore, Swallowing Problem

    Dysphagia Journal Reviewer for 2014

    Dysphagia Reviewer 2014

    Feeling happy and honoured to see my name listed as one of the reviewer along side with all the world reknown dysphagia experts on the acknowledgment of reviewers page in the Dysphagia Journal for 2014. It has a great experience being a reviewer for this distinguished international journal for the very first time. Hope to have the opportunity to review more papers in future.

    Cost effective treatment, Dysphagia Therapy, Singapore, Swallowing Problem

    Surface Electromyography (sEMG) Fatigue Analysis Comparing Chin Tuck against Resistance (CTAR) Against the Shaker Exercise

    CTAR Poster
    CTAR Poster

    This poster was presented at the recent Dysphagia Research Society 23rd Annual Meeting at Illinois, Chicago, USA (12-14 March 2015).

    Title: Surface Electromyography (sEMG) Fatigue Analysis Comparing Chin Tuck against Resistance (CTAR) Against the Shaker Exercise


    Both Shaker and Chin Tuck against Resistance (CTAR) exercises were designed to improve swallowing through the strengthening of the suprahyoid muscles. However, a major limitation of the Shaker exercise was its early fatiguing of the sternocleidomastoid (SCM)(White et al., 2008). In this study, we investigated the extent CTAR recruits the suprahyoid and whether it fatigues SCM. Amplitude and fatigue analyses on sEMG data from 39 adults revealed that unlike Shaker exercise, CTAR was able to recruit the suprahyoid muscle, without substantially fatiguing SCM.


    • Shaker exercise increases UES opening by improving contraction of suprahyoid muscles (Shaker et al., 1997).
    • However, patient compliance was poor (50% attrition; e.g., Easterling et al., 2005).
    • Poor compliance of Shaker exercise was linked to muscle fatigue of auxiliary muscles, namely SCM (White et al., 2008). CTAR exercise was a response to this limitation.
    • Preliminary evidence for CTAR (N = 40 healthy adults; Yoon et al., 2014): (a) Greater sEMG values (amplitude) obtained from Suprahyoid during CTAR than during Shaker exercise. (b) Overall, participants reported CTAR as less strenuous.
    • Research Questions:
    1. Yoon et al’.s data was based on 10-sec isometric trials. The actual CTAR and Shaker exercises require 60 secs each. Will evidence on suprahyoid muscle strength still hold for CTAR when exercise duration is increased to 60 secs?
    2. Main disadvantage for Shaker exercise was its fatiguing of auxiliary muscles beyond the suprahyoid, i.e., SCM. Is CTAR able to demonstrate that it does not suffer this same limitation (i.e., fatiguing of SCM)?



    • N = 39 healthy adults (20 males, 19 females; mean age = 29.82, SD = 5.09).
    • Each participant completed CTAR and Shaker twice in randomized counterbalanced order. 4-min rest in between each exercise.

    sEMG Recording:

    • Single-use pre-gelled electrode patches used (Figure 1; one placed on suprahyoid, the other on SCM).
    • sEMG collected by MyoTrac Infiniti encoder (2048 Hz).

    CTAR Exercise (Figure 2):

    • Seated upright; shoulders not slouched.
    • Executed chin tuck, squeezing an inflatable rubber ball (12 cm diameter) between the base of chin and manubrium sterni for 60 secs.

    Shaker Exercise (Figure 3):

    • Lie supine on an exercise mat.
    • Perform a head lift for 60 secs, shoulder not raised.

    Data Processing:

    First and final 7 secs from each exercise interval discarded to eliminate noise. – MATLAB (Welsch Method) used to generate the power spectra density data.


    • 2 x 2 ANOVA was conducted on each variable.
    • Suprahyoid registered sig. greater (ps < .001) values during CTAR than Shaker. SCM registered sig. greater (ps < .001) values during Shaker than CTAR.
    • Suprahyoid registered sig. greater (ps ≤ .02) fatigue during CTAR than Shaker. SCM registered sig. greater (ps ≤ .002) fatigue during Shaker than CTAR.
    • Rate of change in fatigue for Suprahyoid: CTAR = Shaker (ps > .10). Rate of change in fatigue for SCM: Sig. lesser (ps ≤ .01) during CTAR than Shaker


    • Converging data across two amplitude measures suggest that motor unit recruitment (thus muscle strength) for Suprahyoid was significantly greater during CTAR.
    • Converging data across four fatigue measures suggest that fatigue in SCM was significantly lesser during CTAR than the Shaker exercise.
    • Extends supporting evidence on CTAR’s usefulness in targeting Suprahyoid (SCM not as actively recruited), when conducted in its full 60-secs duration.
    • Clinical trials of CTAR on dysphagic patients recommended as follow-up.