Dysphagia Knowledge Hub — 吞嚥困難知識庫

Shaker Exercise vs Chin Tuck Against Resistance (CTAR) for Dysphagia

When the upper esophageal sphincter (UES) does not open widely enough during a swallow, residue collects in the pyriform sinuses, post-swallow aspiration risk rises, and patients describe a “stuck” sensation in the throat. The two most widely studied rehabilitation exercises for this problem both target the same muscle group — the suprahyoids — but they look different at the bedside, feel different to the patient, and carry different risks. This guide walks through the Shaker head-lift exercise and the newer Chin Tuck Against Resistance (CTAR), the evidence base for each, and how speech-language pathologists choose between them in 2026 practice.

Why suprahyoid strength matters in swallowing

The suprahyoid complex — mylohyoid, geniohyoid, anterior digastric, and stylohyoid — pulls the hyoid bone upward and forward at the moment of swallow. This anterior hyolaryngeal excursion is what physically tugs the UES open and helps the larynx tilt forward to protect the airway. When suprahyoid strength is reduced (after stroke, prolonged intubation, head and neck radiotherapy, or simply with sarcopenia), the UES opens less widely, less completely, and for less time. The result is the classic videofluoroscopic picture of pharyngeal residue at the valleculae and pyriform sinuses, sometimes followed by post-swallow aspiration.

Both Shaker and CTAR aim to load these suprahyoid muscles in isolation — minimising contribution from the sternocleidomastoid (SCM) and other neck flexors that ordinarily dominate head movement.

The Shaker exercise: the original protocol

The Shaker head-lift exercise was published by Reza Shaker and colleagues in 1997, after they showed in healthy older adults that a structured 6-week program increased UES anteroposterior opening diameter and reduced hypopharyngeal intrabolus pressure. The original protocol is precise and demanding:

Standard Shaker protocol

Patient lies flat (supine) on a firm surface, no pillow.
Isometric phase: raise the head high enough to look at the toes, hold for 60 seconds. Lower fully and rest for 60 seconds. Repeat 3 times.
Isokinetic phase: raise and lower the head 30 consecutive times, lifting only the head — the shoulders must stay flat against the surface.
Performed three times per day for six weeks.

The mechanism is direct: holding the head off the floor against gravity is a sustained isometric load on the suprahyoids and infrahyoids; the 30 repetitions add an isotonic component. In Shaker’s 2002 follow-up study of tube-fed patients with abnormal UES opening, six weeks of the protocol allowed a substantial subset to return to oral intake and have their feeding tubes removed.

A more recent 2022 randomised controlled trial in head and neck cancer survivors evaluated the Shaker protocol against a sham control with videofluoroscopic outcomes. Adherence was a major theme: patients found the supine head-lift physically taxing, and benefits were modest in those who could not complete the prescribed dose.

Why the Shaker protocol fails some patients

In real-world rehabilitation, the Shaker exercise has well-documented limitations:

Cervical spine restriction. Patients with cervical fixation hardware, post-surgical neck collars, fused vertebrae, or significant cervical osteoarthritis often physically cannot achieve the head-lift posture. A 2022 case series of spinal injury patients reported that no enrolled patient could complete the Shaker head-lift.
Frailty and cardiovascular load. The 60-second sustained head-lift is essentially a sustained isometric neck flexion — taxing for older adults with sarcopenia, recent cardiac events, or high-grade hypertension.
SCM substitution. Patients fatigue quickly and recruit the SCM to compensate. Surface electromyography (sEMG) studies show that healthy adults performing Shaker activate SCM at higher levels than CTAR — meaning some of the “work” is going to the wrong muscle.
Compliance. Three sets, three times per day, for six weeks, lying flat on the floor each time, is a high-friction prescription. Adherence rates in community studies are routinely below 50%.

These limitations are why Yoon and colleagues introduced CTAR in 2013 — explicitly framed as a “Shaker-type” alternative that loaded the suprahyoids without the head-lift posture.

Chin Tuck Against Resistance (CTAR): the modern alternative

CTAR keeps the patient upright. A soft rubber ball (originally a 12 cm diameter inflatable ball; later devices include the PhagiaFlex and similar commercial tools) is placed between the chin and the sternum. The patient tucks the chin downward, compressing the ball against the upper chest.

Standard CTAR protocol

Patient sits upright in a chair, feet flat, shoulders relaxed.
Place a 12 cm rubber ball under the chin, resting against the upper sternum.
Isometric phase: tuck the chin firmly into the ball and hold for 30–60 seconds. Rest. Repeat 3 times.
Isokinetic phase: perform 30 successive forceful chin tucks against the ball.
Performed three times daily for six weeks.

Some published protocols vary — Park et al. used a 30-second sustained squeeze with simultaneous effortful swallows, followed by 10–30 dynamic compressions. Others recommend holding to fatigue, typically 30–90 seconds, repeated three to five times. The common thread is that the load is generated by chin-on-sternum resistance, not by lifting head against gravity.

A 2024 multidirectional CTAR variant (chin tuck combined with lateral and rotational loading) showed additional gains in suprahyoid sEMG amplitude and tongue pressure compared to single-direction CTAR — suggesting the protocol still has room for refinement.

Head-to-head evidence: what the systematic reviews say

Three key systematic reviews — Park et al. (2021) in the Journal of Oral Rehabilitation, Liu et al. (2022) in Frontiers in Neurology, and the ASHA Evidence Map summary — converge on a consistent picture:

1. CTAR produces equal or greater suprahyoid activation. sEMG studies in healthy adults show CTAR generates suprahyoid activation comparable to Shaker, while activating the SCM significantly less. In other words, CTAR is more target-specific: more of the work goes to the muscles that matter for swallowing.

2. CTAR yields better penetration-aspiration scores in stroke. The 2022 meta-analysis pooled nine post-stroke trials (n=548) and found CTAR significantly improved Penetration-Aspiration Scale (PAS) scores compared to both no-exercise control and the Shaker exercise. Functional Oral Intake Scale (FOIS) and Standardized Swallowing Assessment scores also favoured CTAR.

3. CTAR is dramatically better tolerated. Across studies, dropout rates with CTAR are lower than with Shaker, particularly in older and frailer patients. Patients describe CTAR as less fatiguing, less cardiovascularly taxing, and easier to fit into daily life because it can be done sitting in a chair.

4. Quality and generalisability caveats. Most CTAR trials originate from South Korea and China. Sample sizes are modest. Blinding is difficult given the visible nature of the exercises. Long-term durability of gains beyond 6–12 weeks is poorly characterised. Reviewers consistently call for larger multi-centre RCTs in Western and Southeast Asian populations.

Which patient gets which exercise?

In our clinical experience and consistent with current evidence:

Choose CTAR first-line for:

Frail older adults with sarcopenic dysphagia
Post-stroke patients in subacute and chronic phases
Patients with cervical spine pathology, fixation hardware, or limited neck flexion
Patients with significant cardiovascular comorbidities where sustained supine isometric loading is risky
Anyone you anticipate will struggle with the floor-based supine posture (most home-based community patients)
Patients who have tried and abandoned Shaker due to fatigue or neck discomfort

Consider Shaker for:

Younger, fitter patients with isolated UES opening dysfunction and good cervical mobility
Tube-fed patients with documented UES dysfunction where the original Shaker evidence is most direct
Settings where no resistance device (ball or commercial CTAR tool) is available
Patients already established on Shaker who are progressing and tolerating the load

Avoid both in patients with acute cervical injury, undiagnosed neck pain, recent cervical surgery (until cleared), severe uncontrolled hypertension, recent retinal surgery (Valsalva risk), or active cervical radiculopathy. Always discuss with the medical team if any of these are present.

Combining suprahyoid exercises with the rest of the rehabilitation toolkit

CTAR and Shaker do not work in isolation. Best practice in 2026 is to layer them within a broader swallowing rehabilitation plan:

Effortful swallow every meal — a free, unequipped exercise that increases tongue base retraction.
Mendelsohn maneuver for patients who can volitionally hold laryngeal elevation, which directly trains UES opening duration.
Tongue-strengthening with the Iowa Oral Performance Instrument (IOPI) or tongue depressor isometrics — addresses the oral-stage component that CTAR/Shaker do not.
Expiratory Muscle Strength Training (EMST) — addresses cough strength and submental contribution from a respiratory angle. See our companion guide on EMST for dysphagia.
NMES (VitalStim) in selected cases — when used, it should supplement active exercise, not replace it. See our NMES evidence review.

Suprahyoid strengthening is the structural foundation; the other components address timing, coordination, and airway protection.

Practical setup tips for caregivers and patients

A few details that often determine success or failure of CTAR at home:

Ball selection. A 12 cm diameter is standard, but neck length varies. The ball should rest comfortably between chin and upper sternum, fully filling the gap when the patient is sitting upright in neutral posture. Children’s playground balls, hand-therapy balls, and dedicated devices like PhagiaFlex all work — pick whatever the patient will actually use.
Posture check. Shoulders down and back, no shrugging. If the patient is hunching the shoulders to drive the chin into the ball, the SCM is doing the work — re-cue.
Isolate the chin tuck. The motion should look like the patient is making a “double chin,” not bowing the head forward. The head stays roughly vertical; only the chin drops.
Target sensation. Patients should feel work in the front of the throat under the jaw, not in the back of the neck. Pain in the back of the neck or jaw means recruitment has shifted.
Frequency over duration. Three short sessions a day, every day, beats one heroic session per week. Set the prescription to fit the patient’s schedule.
Progress monitoring. Re-assess at 3 and 6 weeks with a validated tool — EAT-10, FOIS, or videofluoroscopy if available. If no improvement is seen by 6 weeks, the diagnosis or the exercise selection should be re-examined.

Bottom line for clinicians and caregivers

The evidence base in 2026 supports CTAR as the default first-line suprahyoid strengthening exercise for most dysphagia patients, particularly those with stroke, sarcopenic dysphagia, or any factor that limits supine head-lift tolerance. The Shaker exercise remains a reasonable choice for younger, fitter patients without cervical or cardiovascular limitations, and retains the strongest direct evidence for the specific population it was originally tested in (tube-fed patients with abnormal UES opening). In practice, the exercise that the patient will actually perform three times a day for six weeks is the one that works — and on adherence grounds alone, CTAR usually wins.

For families and caregivers reading this guide: do not begin either exercise without an evaluation by a speech-language pathologist or rehabilitation physician. UES opening problems must be confirmed (ideally by videofluoroscopy or FEES), other contributing factors ruled out, and the protocol tailored to the individual patient. Both exercises are powerful tools — but they target one specific deficit, and applying them blindly to a different swallowing problem wastes precious rehabilitation time.