NeuroRehabilitation 42 (2018) 191–197 191

DOI:10.3233/NRE-172250
IOS Press

Effect of chin tuck against resistance

exercise on patients with dysphagia
following stroke: A randomized
pilot study
Ji-Su Parka , Duk-Hyun Anb , Dong-Hwan Ohc and Moon-Young Changd,∗
a Department of Rehabilitation Science, Graduate School of Inje University, Republic of Korea
b Department of Physical Therapy, Inje University, Gimhae, Republic of Korea
c Department of Occupational Therapy, Kyungdong University, Wonju, Republic of Korea
d Department of Occupational Therapy, Inje University, Gimhae, Republic of Korea

Abstract.
BACKGROUND: Recently, chin tuck against resistance exercise (CTAR) has been reported as a remedial treatment for
pharyngeal dysphagia. However, the clinical evidence of the effect is still lacking.
OBJECTIVE: This study investigated the effect of CTAR on the swallowing function in patients with dysphagia following
subacute stroke.
METHODS: The patients were randomly assigned to an experimental (n = 11) or a control group (n = 11). The experimental
group performed CTAR using the CTAR device. The control group received only conventional dysphagia treatment. Both
groups received training on five days a week, for four weeks. The swallowing function was measured using functional
dysphagia scale (FDS) and penetration-aspiration scale (PAS), based on a videofluoroscopic swallowing study (VFSS).
RESULTS: The experimental group showed more improvements in the oral cavity, laryngeal elevation/epiglottic closure,
residue in valleculae, and residue in pyriform sinuses of FDS and PAS compared to the control group (p < 0.05, all).
CONCLUSIONS: This study demonstrated that CTAR is effective in improving the pharyngeal swallowing function in
patients with dysphagia after stroke. Therefore, we recommend CTAR as a new remedial training alternative to HLE.

Keywords: Aspiration, chin tuck against resistance, dysphagia, stroke, rehabilitation

1. Introduction with the swallowing reflex and contraction of the

Rehabilitative treatment is important to improve
function in the oropharyngeal phase of swallowing
in patients with dysphagia, as this phase is directly
related to aspiration, which can cause pneumonia and
even death (Bahia, Mourao, & Chun, 2016; Lim, Lee,
Yoo, & Kwon, 2014). The pharyngeal phase begins
∗ Address for correspondence: Moon-Young Chang, Depart-
ment of Occupational Therapy, Inje University, 197 Inje-ro,
Gimhae, Gyeongsangnam-do, 621-749, Gimhae, Republic of
Korea. Tel.: +82 55 320 3685; Fax: +82 55 326 4885; E-mail:
myot@inje.ac.kr.
suprahyoid muscles (SHM) in the anterior region of
the neck (Kim, Choi, Yoo, Chang, Lee, & Park, 2017).
The SHM connect the jaw to the hyoid bone, and
comprise of the mylohyoid, geniohyoid, and digastric
muscles (Pearson, Langmore, Yu, & Zumwalt, 2012).
The contractions of these muscles contribute to the
normal swallowing mechanism by pulling the hyoid
bone antero-superiorly, then closing the epiglottis and
relaxing the upper esophageal sphincter (Kendall &
Leonard, 2011; Matsuo & Palmer, 2008). In other
words, SHM play an important role in safe swallow-
ing in the pharyngeal phase.

1053-8135/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
192 J.-S. Park et al. / Effect of chin tuck against resistance exercise
However, neurological diseases such as stroke can
weaken the SHM, which may result in decreased
hyoid bone movement, vallecular/pyriform sinus
residue, and aspiration or penetration (Cook et al.,
1989). Therefore, an intervention to strengthen the
SHM in the pharyngeal phase is important as a reme-
dial method.
Various therapeutic methods for enhancing SHM
activity in the pharyngeal phase have been reported.
These include electrical stimulation, effortful swal-
lowing, tongue resistance exercise, and expiratory
muscle strength training. The head lift exercise (HLE)
is commonly used in clinical practice because it can
enhance SHM activity and is noninvasive, inexpen-
sive, and safe. The HLE involves lifting the head
against the pull of gravity and head weight, from
a supine position. This exercise has been known to
be effective in improving the pharyngeal phase with
less risk of aspiration, better clearance of the pharyn-
geal residue, and improved relaxation of the upper
esophageal sphincter, by promoting activation of the
SHM in those vulnerable to swallowing disorders,
such as elderly individuals and patients with a vari-
ety of diseases (Park, Hwang, Oh, & Chang, 2017;
Shaker et al., 1997). However, according to previ-
ous studies, HLE has several limitations. First, it
has to be performed in a supine position. Therefore,
the elderly or patients with neurological disorders,
who need space and cannot easily adjust posture,
may find it difficult to perform. Second, HLE has
a high dropout rate, as it requires excessive effort.
Third, HLE has an aspect of inefficiency due to
excessive efforts on the SCM and abdominal muscles
(Easterling, Grande, Kern, Sears, & Shaker, 2005).
These problems can affect treatment compliance and
effectiveness. Therefore, an alternative approach is
needed.
Recently, several studies have reported a modi-
fied method to compensate for the limitations of the
existing HLEs (Hughes & Watts, 2016; Watts, 2013;
Yoon, Khoo, & Rickard Liow, 2014). A method of
training the SHM by placing an elastic rubber ball
with resistance on the chin and sternum, and then
tucking the chin against the resistance has been pro-
posed (Yoon, Khoo, & Rickard Liow, 2014). The
results of performing CTAR in normal adults demon-
strate increased activation of the SHM; the activation
was comparable with that achieved by the HLE. On
the other hand, subjects reported subjective feed-
back that CTAR was less strict than HLE. In other
words, CTAR has been shown to induce a more
or similar degree of activation of SHM in a more
comfortable way than HLE. Gao and colleagues
also compared CTAR using an inflatable rubber ball
with HLE in patients with dysphagia after stroke
(Gao & Zhang, 2016). CTAR had a positive effect
on psychological status and depression and reduced
aspiration/penetration in stroke patients with dyspha-
gia. Previous studies, however, had some limitations.
First, most studies measured only the immediate acti-
vation of SHM in normal adults. Second, the studies
did not evaluate the detailed function of the oropha-
ryngeal phase in patients with dysphagia after stroke.
Therefore, the effect of CTAR on dysphagic patients
is still unclear and lacks evidence. This study investi-
gates the effect of CTAR on the swallowing function
in patients with dysphagia after stroke, based on pre-
vious studies.
2. Methods
2.1. Study design
This study was designed as a single blind, random-
ized trial.
2.2. Participants
Patients with dysphagia undergoing rehabilitation
were recruited for this study as subjects (n = 25),
according to the following inclusion criteria: 1)
dysphagia following stroke was confirmed by a
videofluoroscopic swallowing study (VFSS), 2) the
onset duration was <12 months, 3) the patients
were able to swallow voluntarily, 4) the Mini-Mental
State Examination score was ≥20, 5) ability to
sit without assistance, and 6) ability to perform
chin tuck using the CTAR device. The exclusion
criteria were as follows: 1) secondary stroke; 2)
severe communication disorders, such as severe apha-
sia, dementia, etc.; 3) pain in the neck region; 4)
unstable medical conditions; and 5) head and neck
cancer. We explained the objective and require-
ments of our study to all participants, and they
voluntarily signed informed consent forms. Ethi-
cal approval was obtained from the Inje University
Institutional Review Board before conducting the
experiment.
2.3. Procedures
The participants were randomly allocated to an
experimental group (n = 13) or a control group
 J.-S. Park et al. / Effect of chin tuck against resistance exercise
(n = 12) by blocked randomization to ensure an equal
number in both groups. The experimental group
performed CTAR using a CTAR device (ISO-CTAR
Device, Alternative Speech and Swallowing Solu-
tions) in a sitting position on a chair.
The CTAR method was applied similar to the
existing HLE method and isometric and isotonic exer-
cises were performed separately (Park et al., 2017).
In isometric CTAR, the patients are asked to chin
tuck against device 3 times for 60 s with no rep-
etition. In isotonic CTAR, the patient performs 30
consecutive repetitions by strongly pressing against
the resistance of the device and releasing it again
(Fig. 1).
To perform the CTAR correctly, the therapist
explained and demonstrated the exercise methods to
all patients before the intervention. We especially
emphasized on the correct chin tuck posture, so that
the patients do not flex their heads against the devices.
We also instructed them to press as strongly as pos-
sible for greater activation of the SHM.
Both groups received the same conventional dys-
phagia treatment (CDT) such as orofacial muscle
exercises, thermal tactile stimulation, and therapeu-
tic or compensatory maneuvers. An experienced
occupational therapist performed the CDT in all
Fig. 1. Chin tuck against resistance training.
193
participants for 30 min/day, five days a week, for 4
weeks. All interventions were performed by an occu-
pational therapist with 7 years of clinical experience
in treating dysphagia. A flowchart of this study is
shown in Fig. 2.
2.4. Outcome measures
The oropharyngeal swallowing function was mea-
sured by the functional dysphagia scale (FDS) and
the penetration-aspiration scale (PAS) based on a
videofluoroscopic swallowing study. VFSS was per-
formed by experienced radiologists and rehabilitation
physicians.
The FDS is a functional evaluation scale that
comprehensively reflects the overall oropharyngeal
swallowing function in stroke patients based on the
VFSS findings (Han, Paik, & Park, 2001). The FDS
consists of 11 items with weighted values repre-
senting 4 oral (lip closure, bolus formation, residue
in oral cavity, oral transit time) and 7 pharyngeal
(triggering of pharyngeal swallow, laryngeal eleva-
tion and epiglottic closure, nasal penetration, residue
in valleculae, residue in pyriform sinuses, coating
of pharyngeal wall after swallow, pharyngeal transit
time) functions that can be observed by VFSS.
194 J.-S. Park et al. / Effect of chin tuck against resistance exercise
Fig. 2. Flowchart of this study.
The PAS is a standard tool that reflects laryn-
geal penetration and aspiration. The scale is broken
down into eight different levels based on the depth
of material penetration into the airway and whether
the material entering the airway is expelled; higher
levels indicate higher aspiration severity (Rosenbek,
Robbins, Roecker, Coyle, & Wood, 1996). FDS and
PAS scores were interpreted by one rehabilitation
physician.
2.5. Data analysis
Participants’ characteristics were analysed using
IBM SPSS Statistics version 20 (IBM Corp.,
Armonk, NY, USA). Descriptive statistics are pre-
sented as means with standard deviations. The
Wilcoxon signed-rank test was used to compare the
differences in outcome measurement before and after
intervention. The Mann–Whitney U-test was used
to compare pre- and post-intervention data between
groups. The significance level was set at p < 0.05.
In addition, the effect sizes (Cohen d) calculated by
dividing the standardized mean difference between
the two groups by using the pooled standard devia-
tion. Effect size of 0.2, 0.5 and 0.8 represent a small,
moderate or large effect respectively.
3. Results
3.1. Participants
In total, 22 participants completed this study.
Three participants dropped out prior to the follow-
up because of discharge. A summary of the clinical
and demographic features of the subjects (n = 22) is
shown in Table 1. The table also shows that no signif-
icant differences in the baseline characteristics were
observed between the two groups (p > 0.05).
3.2. FDS assessment
The experimental group showed more improve-
ment in the residue in oral cavity, laryngeal
elevation/epiglottic closure, residue in valleculae,
and residue in pyriform sinuses of FDS assessment,
when compared with the control group (p = 0.044,
0.039, 0.037, 0.047, respectively) (Table 2). In a
comparison of the amount of change in the groups,
both groups showed significant differences in oral
cavity, laryngeal elevation/epiglottic closure, residue
in valleculae, and residue in pyriform sinuses of
FDS (p = 0.011, 0.024, 0.015, 0.005, respectively)
(Table 3).
 J.-S. Park et al. / Effect of chin tuck against resistance exercise 195

3.3. PAS assessment nificant differences in PAS assessment (p = 0.032)

(Table 3).
The experimental group showed more improve-
ment in the PAS, when compared to the control group
(p = 0.043) (Table 2). In a comparison of the amount
4. Discussion
of change in the groups, both groups showed sig-
This study investigated the effect of CTAR on
Table 1 the swallowing function in patients with dysphagia
Characteristics of participants after stroke. Both groups (experiment and control)
Characteristics Experimental Control showed significant improvements in the swallowing
group group function; however, on comparing the two groups after
(n = 11) (n = 11)
the intervention, it was found that the CTAR-treated
Age (year), mean ± SD (range) 62.16 ± 17.27 58.43 ± 12.51
(43–81) (46–79) group showed more improvement in swallowing,
Gender(n) compared to the CDT-only control group. Therefore,
Men 6 4 this study demonstrated the efficacy of CTAR. The
Women 5 7 results of this study can be explained with several
Type of stroke (n)
Hemorrhage 4 5 reasons.
Infarction 7 6 First, the basic principle of CTAR is resistance
Site of stroke lesion (n) exercise. We used the CTAR device to apply the
Middle cerebral artery 7 9
resistance. Resistance exercises provide more load-
Internal capsule 2 1
Basal ganglia 2 1 ing on the target muscle than other types of exercise,
Paretic side (n) which activate the muscle. Several previous stud-
Right 6 4 ies have demonstrated that CTAR causes similar or
Left 5 7
Time after stroke (weeks) 37.24 ± 8.54 32.14 ± 14.38
greater activation of the SHM than HLE (Hughes &
(27–56) (21–63) Watts, 2016; Watts, 2013; Yoon, Khoo, & Rickard
Feeding type (n) Liow, 2014). Greater muscle activation means that a
Oral feeding 4 5 large number of motor units are recruited, resulting
Tube feeding 7 6
Other deficit (n)
in greater muscle contraction (Park, Oh, Chang, &
Dysarthria 1 0 Kim, 2016). CTAR induces greater muscle activation,
Facial palsy 2 2 which can be expected to result in muscular hyper-
SD: standard deviation. trophy and greater muscle strength, when performed

Table 2
Changes in parameters before and after the treatment
Experimental group Control group Between Effect
Before After P-value Before After P-value groups size
treatment treatment treatment treatment P-values
FDS
LC 2.73 ± 2.61 1.82 ± 2.52 0.157 2.27 ± 2.61 2.27 ± 2.61 1 0.672 0.35
BF 2.09 ± 1.76 1.27 ± 1.85 0.083 1.82 ± 1.83 1.36 ± 1.57 0.45 0.82 0.21
ROC 2.18 ± 1.66 0.45 ± 0.82 0.010∗ 1.82 ± 1.66 1.64 ± 1.5 0.564 0.044† 1.44
OTT 3.27 ± 3.13 2.18 ± 2.71 0.102 2.73 ± 2.83 1.82 ± 2.27 0.109 0.772 0.07
TPS 3.18 ± 4.05 1.82 ± 2.52 0.083 2.73 ± 4.67 1.82 ± 3.37 0.157 0.778 0.15
LEEC 8.55 ± 5.52 3.1 ± 2.73 0.011∗ 7.09 ± 5.09 5.5 ± 3.24 0.045∗ 0.039† 1.21
NP 3.27 ± 3 2.55 ± 3.24 0.157 2.73 ± 2.57 2.18 ± 1.89 0.257 0.943 0.05
RV 5.45 ± 2.02 2.18 ± 1.89 0.01∗ 4.73 ± 1.62 4 ± 1.55 0.102 0.037† 1.48
RPS 4.73 ± 2.41 1.64 ± 1.96 0.007∗ 4 ± 2.53 3.64 ± 2.34 0.414 0.047† 1.3
CPW 2.28 ± 4.1 1.36 ± 3.23 0.157 1.36 ± 3.23 0.91 ± 2.02 0.317 0.922 0.17
PTT 1.82 ± 2.09 1.09 ± 1.87 0.157 1.64 ± 1.96 1.45 ± 2.02 0.317 0.655 0.28
Total 38.64 ± 18.41 22.36 ± 11.57 0.003∗ 33.18 ± 16.23 27.18 ± 14.21 0.028∗ 0.45 0.79
PAS 5.73 ± 1.19 3.55 ± 1.29 0.012∗ 5.18 ± 1.6 4.73 ± 1.27 0.347 0.043† 1.3
SD: standard deviation. ∗ p < 0.05 by Wilcoxon test, † p < 0.05 by Mann-Whitney U test. FDS: Functional dysphagia scale, LC: Lip closure, BF:
Bolus formation, ROC: Residue in oral cavity, OTT: Oral transit time, TPS: Triggering of pharyngeal swallow, LEEC: Laryngeal elevation
and epiglottic closure, NP: Nasal penetration, RV: Residue in valleculae, RPS: Residue in pyriform sinuses, CPW: Coating of pharyngeal
wall after swallow, PTT: Pharyngeal transit time, PAS: Penetration-aspiration scale.
196 J.-S. Park et al. / Effect of chin tuck against resistance exercise

Table 3 increase in the tongue volume and muscle strength in

Comparison of FDS, PAS in both of groups after intervention patients with dysphagia after stroke for 4 weeks (Rob-
Experimental Control Between bins et al., 2007). Therefore, this study also suggests
group group group
that the 4-week CTAR training may have affected the
(Mean ± SD) (Mean ± SD) p-value
increase in the strength of the SHM.
FDS
LC 0.91 ± 2.02 0 ± 2.23 0.328 This study attempted to maximize the effect of
BF 0.82 ± 1.4 0.45 ± 1.69 0.66 CTAR as follows. The SHM group is a small group of
ROC 1.9.±1.42 0.18 ± 1.08 0.011† muscles located between the mandibular and hyoid
OTT 1.09 ± 2.02 0.91 ± 1.92 0.933 bones. Therefore, neck flexion should be avoided
TPS 1.36 ± 2.34 0.9 ± 2.02 0.619
LEEC 5.72 ± 4.31 2.09 ± 2.91 0.024† in order to stimulate them selectively; neck flexion
NP 0.73 ± 1.62 0.55 ± 1.57 0.933 against resistance makes it difficult to contract the
RV 3.27 ± 2.57 0.73 ± 1.35 0.015† SHM. Thus, the therapist continuously monitored
RPS 3.09 ± 2.07 0.36 ± 1.5 0.005† the patients while they were performing CTAR, and
CPW 0.91 ± 2.02 0.45 ± 1.51 0.544
PTT 0.73 ± 1.62 0.18 ± 0.6 0.474 incorrect postures were not counted in the number of
Total 16.27 ± 9.79 6 ± 7.14 0.016† training sessions. Previous studies have also reported
PAS 2.18 ± 1.83 0.45 ± 1.63 0.032† that caution is needed when performing isotonic
SD: standard deviation. † p < 0.05 by Mann-Whitney U test. FDS: training with CTAR (Yoon, Khoo, & Rickard Liow,
Functional dysphagia scale, LC: Lip closure, BF: Bolus forma- 2014). Isotonic training is a method of repeating chin
tion, ROC: Residue in oral cavity, OTT: Oral transit time, TPS: tuck against resistance. It is divided into concen-
Triggering of pharyngeal swallow, LEEC: Laryngeal elevation
tric and eccentric exercise, and both are important
and epiglottic closure, NP: Nasal penetration, RV: Residue in
valleculae, RPS: Residue in pyriform sinuses, CPW: Coating of factors for muscular strengthening through the resis-
pharyngeal wall after swallow, PTT: Pharyngeal transit time, PAS: tance exercise. Concentric exercise involves a chin
Penetration-aspiration scale. tuck posture against resistance, and the loading is
sufficient for the SHM. In contrast, returning to the
original position from the chin tuck posture, i.e.,
repeatedly. Therefore, CTAR in this study may have eccentric contraction of the SHM involves little or
affected the SHM strength in stroke patients. no loading of the SHM. This happens as the elastic
Second, activation of the SHM and improvement nature of the rubber ball or CTAR device enables it to
in muscle strength through resistance training con- return to its original shape. Therefore, this study indi-
tribute to normal swallowing. The mechanism of cated that when performing eccentric contraction of
normal swallowing is shifted from the oral cav- isotonic training, it should be turned back to its orig-
ity to the pharynx through chewing, conditioning, inal posture against resistance with slow, controlled
and formation of bolus. At this time, contraction of movements.
the SHM occurs with swallowing reflex (Park, Oh, This study, however, has some limitations. First,
Hwang, & Lee, 2016). The contraction of the SHM it is difficult to generalize the results of this study
pulls the hyoid and larynx upwards, causing rota- because the sample size was very small, as it was
tion of the epiglottis and helping in airway closure a pilot study. Second, the CTAR device used in this
(Ertekin & Aydogdu, 2003; Lang, 2009). There- study cannot adjust the intensity of resistance, making
fore, we believed that resistance training through it difficult to conduct systematic resistance training.
CTAR helps improve pharyngeal dysphagia, and the Third, the long-term effect is unknown because only
results of this study are similar to those of previous the pre- and post-intervention evaluations were per-
HLE. formed. Finally, this study did not compare CTAR
The effect of resistance training of the skeletal and HLE; thus, we could not judge which treatment
muscles depends on the training period. Previous is more effective.
studies have reported that resistance training in
patients with stroke requires a minimum of 4 weeks to
induce physiological changes in the muscles (Mori- 5. Conclusion
tani & deVries, 1979). Park and colleagues also
demonstrated improvements in the swallowing func- This study demonstrated that CTAR is effective in
tion by HLE performed for 4 weeks as a part of improving the swallowing function in patients with
strength training in patients with dysphagia (Park et dysphagia after stroke. Therefore, CTAR can be rec-
al., 2017). Robbins and colleagues demonstrated an ommended as an alternative to HLE.
 J.-S. Park et al. / Effect of chin tuck against resistance exercise
Conflict of interest
None to report.
Funding
This work was supported by the 2016 Inje Univer-
sity research grant.
References
Bahia, M. M., Mourao, L. F., & Chun, R. Y. (2016). Dysarthria as a
predictor of dysphagia following stroke. NeuroRehabilitation,
38(2), 155-162. doi: 10.3233/NRE-161305
Cook, I. J., Dodds, W. J., Dantas, R. O., Massey, B., Kern, M. K.,
Lang, I. M., Brasseur, J. G., & Hogan, W. J. (1989). Open-
ing mechanisms of the human upper esophageal sphincter.
American Journal of Physiology, 257(5 Pt 1), 748-759.
Easterling, C., Grande, B., Kern, M., Sears, K., & Shaker, R.
(2005). Attaining and maintaining isometric and isokinetic
goals of the Shaker exercise. Dysphagia, 20(2), 133-138.
Ertekin, C., & Aydogdu, I. (2003). Neurophysiology of swallow-
ing. Clin Neurophysiol, 114(12), 2226-2244.
Gao J., & Zhang, H. J. (2016). Comparison of effects on dysphagia
and psychological state after cerebral infarction between chin
tuck against resistance exercise and Shaker exercise. Eur J Phys
Rehabil Med, 10.
Han, T. R., Paik, N. J., & Park, J. W. (2001). Quantifying swallow-
ing function after stroke: A functional dysphagia scale based
on videofluoroscopic studies. Archives of Physical Medicine
and Rehabilitation, 82(5), 677-682.
Hughes, T., & Watts, C. R. (2016). Effects of 2 resistive exercises on
electrophysiological measures of submandibular muscle activ-
ity. Archives of Physical Medicine and Rehabilitation, 97(9),
1552-1557.
Kendall, K. A., & Leonard, R. J. (2001). Hyoid movement during
swallowing in older patients with dysphagia. Archives of Oto-
laryngology - Head and Neck Surgery, 127(10), 1224-1229.
Kim, H. D., Choi, J. B., Yoo, S. J., Chang, M. Y., Lee, S. W., & Park,
J. S. (2017). Tongue-to-palate resistance training improves
tongue strength and oropharyngeal swallowing function in
subacute stroke survivors with dysphagia. Journal of Oral
Rehabilitation, 44(1), 59-64.
Lang, I. M. (2009). Brain stem control of the phases of swallowing.
Dysphagia, 24(3), 333-348.
197
Lim, K. B., Lee, H. J., Yoo, J., & Kwon, Y. G. (2014). Effect
of low-frequency rTMS and NMES on subacute unilateral
hemispheric stroke with dysphagia. Annals of Rehabilitation
Medicine, 38(5), 592-602.
Matsuo, K., & Palmer, J. B. (2008). Anatomy and physiology
of feeding and swallowing: Normal and abnormal. Physical
Medicine and Rehabilitation Clinics of North America, 19(4),
691-707.
Moritani, T., & deVries, H. A. (1979). Neural factors versus hyper-
trophy in the time course of muscle strength gain. American
Journal of Physsical Medicine. 58(3), 115-130.
Park, J. S., Oh, D. H., Hwang, N. K., & Lee, J. H. (2016). Effects of
neuromuscular electrical stimulation combined with effortful
swallowing on post-stroke oropharyngeal dysphagia: A ran-
domised controlled trial. Journal of Oral Rehabilitation, 43(6),
426-434.
Park, J. S., Oh, D. H., Chang, M. Y., & Kim, K. M. (2016). Effects
of expiratory muscle strength training on oropharyngeal dys-
phagia in subacute stroke patients: A randomised controlled
trial. Journal of Oral Rehabilitation, 43(5), 364-372.
Park, J. S., Hwang, N. K., Oh, D. H., & Chang, M. Y. (2017). Effect
of head lift exercise on kinematic motion of the hyolaryn-
geal complex and aspiration in patients with dysphagic stroke.
Journal of Oral Rehabilitation, 44(5), 385-391.
Pearson, W. G., Langmore, S. E., Yu, L. B., & Zumwalt, A. C.
(2012). Structural analysis of muscles elevating the hyolaryn-
geal complex. Dysphagia, 27(4), 445-451.
Robbins, J., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A.
L., Gentry, L. R., & Taylor, A. J. (2007). The effects of lingual
exercise in stroke patients with dysphagia. Archives of Physical
Medicine and Rehabilitation, 88(2), 150-158.
Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., &
Wood, J. L. (1996). A penetration-aspiration scale. Dyspha-
gia,11(2), 93-98.
Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E. T., Hoff-
mann, R. G., Arndorfer, R. C., Hofmann, C., & Bonnevier, J.
(1997). Augmentation of deglutitive upper esophageal sphinc-
ter opening in the elderly by exercise. American Journal of
Physiology, 272(6 Pt 1), 1518-1522.
Watts, C. R. (2013). Measurement of hyolaryngeal muscle acti-
vation using surface electromyography for comparison of
two rehabilitative dysphagia exercises. Archives of Physical
Medicine and Rehabilitation, 94(12), 2542-2548.
Yoon, W. L., Khoo, J. K., & Rickard Liow, S. J. (2014). Chin
tuck against resistance (CTAR): New method for enhancing
suprahyoid muscle activity using a Shaker-type exercise. Dys-
phagia, 29(2), 243-248.