How often have you come across a patient that would be perfect for the Shaker exercise? Perhaps, they are acutely ill or they have tenuous GI issues, thus laying flat would not be an ideal situation. Perhaps, compliance may be a challenge with this particular exercise. I have found alternatives/modifications to the Shaker exercise to be an exciting area of research and can’t wait for it to continue to expand.  One particular exercise that has really peaked my interest was the jaw-opening exercise (Wada 2012). This study investigated the effects of jaw-opening as an exercise to strengthen the suprahyoid muscles in eight dysphagia patients.

The Jaw-opening Exercise

  1. Open jaw to its maximum position and maintain this position for 10 seconds
  2. Then close mouth and rest for 10 seconds
  3. Repeat each exercise set 5x

Hyoid elevation, UES opening, pharynx passage time, pharyngeal residue after swallowing were compared pre and post by VFSS.  Significant improvements were observed in hyoid movement, UES opening and time for pharynx passage. Pharyngeal residue decreased in some subjects. Of course there are some warning signs to this, one of which includes contraindications for patients with TMJ. I would love to see additional articles published on this exercise, as it is simple to implement across the continuum of care.

Seems like a feasible exercise for patients sitting in a chair, huh? Want further modification for this exercise? How about adding some resistance?

CtC and CTAR

The ISO swallowing device addresses this exact exercise with their device to provide resistance. A recent article published online by Watts (2013) supports jaw opening, or chin-to-chest exercise, to promote hyolaryngeal elevation muscle activation. While this study was done with 20 young healthy subjects it provides an excellent spring board into further research into jaw-opening and jaw-opening against resistance as a viable alternative to the Shaker exercise. Additionally, there was a poster session at the 21st Annual Dysphagia Research Society that addressed CTAR (chin tuck against resistance) using an inexpensive small plastic basketball (Khoon 2013). Forty healthy adults were given four exercise tasks. CTAR (chin-tuck against resistance), isometric and isokinetic and shaker isometric and isokinetic. This was in conjunction with sEMG. There was significant difference for Isometric tasks with CTAR and no significant difference between CTAR and Shaker for isokinetic exercise in relation to suprahyoid muscle activity. Benefit was seen that CTAR may be less strenuous than Shaker and compliance and achievement of the exercise may be greater. LESS STRENUOUS AND MORE COMPLIANCE ! Keeping my eyes out for an article that further expands on the poster session.

With everything, we want to make sure we are using best practice. I encourage everyone to read the articles below before introducing these exercises to your patients.

Links of Interest


  1. Khoo, J., Liow, S.J.R., Lam Yoon, W. (2013, March). Comparison of suprahyoid muscles activity between chin-tuck-against-resistance (CTAR) and the shaker exercises. Poster session presented at the 21st Annual Meeting of The Dysphagia Research Society, Seattle, WA.
  2. Satoko W., Haruka T., Takatoshi L., Motoharu I., Mitsuyasu S., Koichiro U. Jaw-Opening exercise for Insufficient opening of upper esophageal sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012
  3. Watts, CR Measurement of Hyolaryngeal Muscle Activation Using Surface Electromyography for Comparison of Two Rehabilitative Dysphagia Exercises, Archives of Physical Medicine and Rehabilitation, Available online 28 April 2013