Effectiveness of Chin Tuck Against Resistance (CTAR) exercise in improving swallowing ability among Cerebrovascular Accident patients with dysphagia at selected Hospital, Erode

2. EFFECTIVENESS OF CHIN TUCK AGAINST RESISTANCE (CTAR)
EXERCISE IN IMPROVING SWALLOWING ABILITY AMONG
CEREBROVASCULAR ACCIDENT PATIENTS WITH DYSPHAGIA
AT SELECTED HOSPITAL, ERODE .
A DISSERTATION SUBMITTED TO THE TAMILNADU
Dr. M.G.R MEDICAL UNIVERSITY, CHENNAI,
IN PARTIAL FULLFILLMENT FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING
MEDICAL SURGICAL NURSING (Critical Care Nursing)
By
VEERABAGU.S B.Sc (N).,
SRESAKTHIMAYEIL INSTITUTE OF NURSING AND RESEARCH
(JKK NATARAJA EDUCATIONAL INSTITUTIONS)
KUMARAPALAYAM (PO),
NAMAKKAL DISTRICT – 638 183
OCTOBER - 2019

3. INTRODUCTION
Dysphagia (from the Greek, "difficulty swallowing")
refers to two related, but distinct, clinical problems. On
the one hand, it refers to a patient's awareness of
impaired transit of swallowed oral contents. On the
other, it refers more generally to any swallowing
disorders that are often, but not always, associated with
dysphagia. Swallowing disorders can present with a
variety of symptoms other than dysphagia. The most
common symptoms are swallow-related coughing and
regurgitation of previously swallowed food or liquid.
Disorders of swallowing may result from problems
with neural control, muscular coordination,
inflammation, or neoplasia.

4. NEED FOR STUDY
• Stroke is a life changing event. Dysphagia can be
seen in 65% of the patients with stroke. In order
to improve the overall outcome after stroke it is
essential that the swallowing and feeding
performance need to be improved through Chin
Tuck Against Resistance (CTAR) Exercise
• So the researcher has decided to conduct,
“Effectiveness of Chin Tuck Against Resistance
(CTAR) exercise in improving swallowing ability
among Cerebrovascular Accident patients”.

5. STATEMENT OF THE PROBLEM
Effectiveness of Chin Tuck Against
Resistance (CTAR) exercise in improving
swallowing ability among Cerebrovascular
Accident patients with dysphagia at selected
Hospital, Erode .

6. OBJECTIVES
• To assess the pre test level of swallowing ability
among cerebrovascular accident patients with
dysphagia.
• To evaluate the effectiveness of Chin Tuck
Against Resistance (CTAR) exercise in
improvement of swallowing ability among
cerebrovascular accident patients with dysphagia.
• To find out the association between post test level
of swallowing ability among cerebrovascular
accident patient and their selected demographic
variables.

7. HYPOTHESIS
• H1 - There will be a significant difference in
pre test and post test swallowing ability
among cerebrovascular accident patients.
• H2 – There will be a significant association
between post test swallowing ability among
cerebrovascular accident patients with their
selected demographic variables.

8. OPERATIONAL DEFINITIONS
Effectiveness:
It refers to the reduction in the swallowing difficulty
after administration of Chin Tuck Against Resistance
(CTAR) exercise which is measured by using Gugging
Swallowing Screening scale (GUSS).
Chin Tuck Against Resistance (CTAR) exercise:
CTAR exercise is an activity performed with a 12cm
diameter inflatable rubber ball which is placed between
chin and base of neck to provide resistance when the
patient is seated in upright position. Chin tuck against
the ball and sustained it for 10 sec (isometric) and for
10 repetitions (isokinetic), three times a day for 8
consecutive days.

9. Swallowing ability:
If patients are able to get the score of 20 in
Gugging Swallowing Screening scale (GUSS),
Then it is concluded that the patient attained
optimal swallowing ability.
Cerebrovascular accident patients:
In this study, it refers to clinically diagnosed
stroke patients with impaired swallowing ability
which could be graded using GUSS scale.
Dysphagia:
Dysphagia, an impairment of the swallowing
mechanism which can be assessed using Gugging
Swallowing Screening scale in patients who have
experienced stroke.

10. ASSUMPTIONS
• Dysphagia can negatively impact the person's
ability to maintain adequate hydration and
nutrition.
• Chin Tuck Against Resistance (CTAR)
exercise may improve swallowing ability
among CVA patients with dysphagia.
DELIMITATIONS
• In this study, it was limited only to the 30
sample size ,only one setting , stroke patients
alone, the period is 8 days only.

11. CONCEPTUAL FRAMEWORK

12. REVIEW OF LITERATURE
For the present study, the investigator reviewed and
organized the literature related to effectiveness of chin
tuck against resistance exercise in improving
swallowing ability among cerebrovascular accident
patients with dysphagia under the following headings.
1. Literature related to cerebrovascular accident with
dysphagia
2. Literature related to chin tuck against resistance
exercise
3. Literature related to improving swallowing ability

13. RESEARCH METHODOLOGY
RESEARCH APPROACH:
Quantitative research approach
RESEARCH DESIGN
For this study is pre experimental one group pre
test - post test design was adopted to evaluate the
effectiveness of swallowing ability among
Cerebrovascular accident patients with dysphagia.
SETTING OF THE STUDY:
The present study is conducted in Neuro unit of
SenthilMultiSpeciality Hospital,Erode.Tamilnadu

14. VARIABLES OF THE STUDY
The present study is,
Independent variable
In this study independent variable is Chin Tuck
Against Resistance (CTAR) exercise
Dependent variable
In this study dependent variables study is
Swallowing ability.
Demographic variables
It includes age in years, gender, educational
status, occupation, residence, monthly income,
bad habits, duration of illness, types of stroke, any
other treatments

15. POPULATION
Target population
In this study, population were includes Cerebrovascular
accident patients with dysphagia patients.
Accessible population
The accessible population for this study were the
patients with cerebrovascular accident patients with
dysphagia who met the inclusion criteria and exclusion
criteria.
Sample
Sample of the present study are cerebrovascular
accident patients with dysphagia who is admitted in
Neuro unit of SenthilMultiSpeciality Hospital, Erode,
Tamilnadu.

16. Sample size
In this study sample size is 30 cerebrovascular
accident with patients with dysphagia.
Sampling technique
Sampling technique is an important step in the
research process. It is the process of selecting
representative units or subsets of a population
of the study in a research.

17. SAMPLE SELECTION CRITERIA
 Inclusion Criteria:
• Patients with,
right or left hemiplegia or hemiparesis.
who are conscious.
who are alert, cooperative and obeys commands.
who can assume sitting position.
who are in limited age of 40 – 70 years
who are willing to participate in the study.
 Exclusion Criteria:
• Patients with,
endotracheal intubation.
tracheostomy.
other neurological disorders like head injuries, spinal cord injury.
who are critically ill.

18. Description of the tool
 SECTION – A : Demographic variables
 SECTION – B : Swallowing assessment
 SECTION – C : Gugging Swallowing Screen scale (GUSS)
GUSS Scale - Score interpretation
Reliability:
• The reliability of the GUSS tool was found to be 0.94.
• The tool was found to be highly reliable for the study.
S.NO ITEMS SCORE
1 NORMAL SWALLOWING ABILITYY 20
2 MILD DYSPHAGIA 15-19
3 MODERATE DYSPHAGIA 10-14
4 SEVERE DYSPHAGIA 0-9

19. PLAN FOR DATA COLLECTION
Both descriptive and inferential statistics will be used to analyze the
data.
 Descriptive statistics:
• Frequency and percentage distribution will be used to analyze the
demographic variables of cerebrovascular accident patients with
dysphagia.
• Mean and standard deviation will be used to assess the outcome
measures of Gugging Swallowing Screen (GUSS) scale before and
after treatment of chin tuck against resistance exercise.
 Inferential statistics:
 Paired ‘t’ Test : This test will be used to find the significant
difference between the pre – test and post test level of swallowing
ability among cerebrovascular accident patients with dysphagia.
 Chi – square test: This test will be used to find out the association
between demographic variables and post test score of swallowing
ability

20. DATAANALYSIS AND INTERPRETATION
DATA ANALYSIS AND INTERPRETATION HAVE BEEN DONE UNDER THE
FOLLWING HEADINGS
 SECTION A
Frequency and percentage distribution of demographic variables of cerebrovascular
accident patients with dysphagia.
 SECTION B
Assess the Swallowing ability among Cerebrovascular accident with dysphagia
patients before and after implementation of Chin Tuck Against Resistance Exercise
(CTAR).
 SECTION C
 Assess the effectiveness of Chin Tuck Against Resistance Exercise among
cerebrovascular accident patients with dysphagia.
 Mean, SD, and Mean percentage and paired “t” value of pre and post test Scores.
 Paired “t” test value of pre and post test scores.
 SECTION D
 Analyzing the association between demographic variables and effectiveness of Chin
Tuck Against Resistance Exercise among cerebrovascular accident patients with
dysphagia.
 Chi – square value of association between the post test score of CTAR exercise and
selected demographic variables

21. S.NO DEMOGRAPHIC VARIABLES NUMBER PERCENTAGE
01.
AGE IN YEARS
40 – 50 years 09 30%
51 – 60 years 12 40%
61 – 70 years 09 30%
02.
GENDER
Male 26 87%
Female 04 13%
03.
EDUCATIONAL STATUS
Illiterate 17 57%
High school 04 13%
Higher secondary school 09 30%
Graduate 0 0%
SECTION – A
FREQUENCY AND PERCENTAGE DISTRIBUTION OF
DEMOGRPHIC VARIBALES OF CEREBROVASCULAR ACCIDENT
PATIENTS WITH DYSPHAGIA.

22. S.NO DEMOGRAPHIC VARIABLES NUMBER PERCENTAGE
04.
OCCUPATION
Coolie 12 40%
Private 06 20%
Government 03 10%
Unemployed 09 30%
05.
RESIDENCE
Urban 04 13%
Rural 26 87%
06.
MONTHLY INCOME
1000 to 5000 17 57%
5001 to 10,000 03 10%
10,001 to 15,000 07 23%
15,001 and above 03 10%

23. S.NO DEMOGRAPHIC VARIABLES NUMBER PERCENTAGE
07.
BAD HABITS
Smoking 09 30%
Alcoholism 08 27%
Tobacco chewing 09 30%
None of the above 04 13%
08.
DURATION OF ILLNESS
Newly diagnosed 16 53%
1 to 3 years 11 37%
3 and above years 03 10%
09.
TYPES OF STROKE
Hemorrhagic Stroke 07 23%
Ischemic Stroke 23 77%
10.
ANY OTHER TREATMENTS
Medical treatments 21 70%
Surgical treatments 05 17%
Physiotherapy 04 13%

24. This table shows the frequency and percentage
distribution of the personal factors of demographic
variables of cerebrovascular accident patients with
dysphagia.
Regarding the age in years , 09 (30%) were aged 40
– 50 years, 12 (40%) were aged 51 – 60 years, 09
(30%) were aged 61 – 70 years of age.
Regarding the gender, 26 (87%) were male, 04 (13%)
were female.
Regards to the Educational status, 17(57%) were
illiterate, 04(13%) were high school, 09 (30%) were
higher secondary, 0(0%) were graduate.
In occupation, 12 (40%) were coolie, 06 (20%) were
private, 03 (10%) were government, 09 (30%) were
unemployed.

25. In Residence, 04 (13%) were urban, 26 (87%) were
rural.
In monthly income, 17(57%) were 1000 – 5000, 03
(10%) were 5001 – 10,000, 07 (23%) were 10,001 –
15,000, 03 (10%) were 15,001 and above.
In bad Habits, 09 (30%) were in smoking, 08 (27%)
were in alcoholism, 09 (30%) were in tobacco chewing,
04 (13%) were none of the above habits.
In Duration of illness, 16 (53%) were newly
diagnosed patients, 11 (37%) were 01 – 03 years, 03
(10%) were 03 and above years of illness.
In types of stroke, 07 (23%) were hemorrhagic stroke,
23 (77%) were ischemic stroke patients.

26. SECTION B
ASSESS THE LEVEL OF SWALLOWING ABILITY BEFORE
AND AFTER CHIN TUCK AGAINST RESISTANCE
EXERCISE
Table.: Frequency and percentage distribution of pre & post test score on
cerebrovascular patients with dysphagia.
Table shows that, total of 30 dysphagic patients 26 (87%) had moderate
dysphagia, 04 (13%) had severe dysphagia during pre test and 03 (10%)
were in normal swallowing ability, 27 (90%) were in mild dysphagia during
post test. It shows that Chin Tuck Against Resistance Exercise was
effective
Level of
swallowing ability
Normal Mild Moderate Severe
No . % No. % No. % No. %
Pre – Test 0 0 0 0 26 87 04 13
Post – Test 03 10 27 90 0 0 0 0

27. SECTION C
EFFECTIVENESS OF CHIN TUCK AGAINST RESISTANCE (CTAR)
EXERCISE IN IMPROVING SWALLOWING ABILITY AMONG
CEREBROVASCULAR ACCIDENT PATIENTS WITH DYSPHAGIA
Table: Mean, SD, and Mean percentage of pre test and post test score.
(n=30)
Table Shows mean, SD, and Mean Percentage of pre and post test scores. The result
shows that the pre test mean was 12 ±1.8 whereas in post test 19 ± 1.6 and the
difference in mean percentage was 35%. The result shows that there was a
significant difference between pre and post test swallowing ability.
Purposively
selected CVA
patients
Max score Mean SD Mean
Percentage
Difference in
mean
percentage
Pre – Test 20 12 1.8 60 % 35 %
Post – Test 20 19 1.6 95 %

28. Table : Paired “t” test value of pre and post test Swallowing
ability of dysphagia patients.
df=29 Table value = 2.05 p<0.05 Significance
Table Shows that , paired “t” test was calculated to analyze the effectiveness
between pre and post test score of swallowing ability among Cerebrovascular
patients with dysphagia. The paired “t” test score was 29, when compared to
table value (2.05) its was high. It seems that the Chin Tuck Against Resistance
Exercise was effective on cerebrovascular patients with dysphagia.
Purposively
selected CVA
patients with
dysphagia
Mean Calculated
Paired ‘t”
value
Degree of
freedom
Table value Level of
significance
Pre – Test 12 29 29 2.05 Significant
Post –Test 19

29. SECTION D
ASSOCIATION BETWEEN THE POST TEST SCORE OF CTAR EXERCISE
AND THEIR SELECTED DEMOGRAPHIC VARIABLES AMONG
CEREBROVASCULAR ACCIDENT PATIENTS WITH DYSPHAGIA.
Table : Chi – Square value of association between the post test score of
dysphagia and their selected demographic variables.
S.No Demographic variables Post test score
Chisquare
Pvalue
Levelof
significance
Normal Mild Moderate Severe
No. % No % No. % No %
1. AGE IN YEARS
40 – 50 years 02 6.6 07 23.3 0 0 0 0 2.82 12.
592
NS
51 – 60 years 0 0 12 40 0 0 0 0
61 – 70 years 01 3.3 08 26.6 0 0 0 0
2. GENDER
Male 02 6.6 24 80 0 0 0 0 1.17 7.8
15
NS
Female 01 3.3 03 10 0 0 0 0

30. S.No Demographic variables Post test score
Chisquare
Pvalue
Levelof
significance
Normal Mild Moderate Severe
No. % No % No. % No %
3. EDUCATIONAL STATUS
Illiterate 02 6.6 15 50 0 0 0 0 2.41 12.59
2
NS
High school 01 3.3 03 10 0 0 0 0
Higher secondary 0 0 09 30 0 0 0 0
Graduate 0 0 0 0 0 0 0 0
4.
OCCUPATION
Coolie 02 6.6 10 33.3 0 0 0 0 2.19 16.91
9
NS
Private 01 3.3 05 16.6 0 0 0 0
Government 0 0 03 10 0 0 0 0
Unemployed 0 0 09 30 0 0 0 0
5. RESIDENCE
Urban 01 3.3 03 10 0 0 0 0
Rural 02 6.6 24 80 0 0 0 0

31. S.
No
Demographic variables Post test score
Chisquare
Pvalue
Levelof
significance
Normal Mild Moderate Severe
No. % No % No. % No %
6. MONTHLY INCOME
1000 to 5000 02 6.6 15 50 0 0 0 0 03 16.
919
NS
5001 to 10,000 01 3.3 02 6.6 0 0 0 0
10,001 to15,000 0 0 07 23.3 0 0 0 0
15,001 and above 0 0 03 10 0 0 0 0
7. BAD HABITS
Smoking 01 3.3 08 26.6 0 0 0 0 1.89 16.
919
NS
Alcoholism 0 0 08 26.6 0 0 0 0
Tobacco Chewing 01 3.3 08 26.6 0 0 0 0
None of the above 01 3.3 03 10 0 0 0 0
8. DURATION OF ILLNESS
Newly diagnosed 02 6.6 14 46.6 0 0 0 0 0.44 12.
592
NS
01 to 03 years 01 3.3 10 33.3 0 0 0 0
03 and above years 0 0 03 10 0 0 0 0

32. S – Significant NS – Non significant
Table shows that , statistically there is a strong significant association between the post test
score of chin tuck against resistance exercise and their demographic variables of residence
among cerebrovascular accident patients with dysphagia and other demographic variables of
age in years, gender, educational status, occupation, monthly income, bad habits, duration of
illness, types of stroke, and any other treatment are non significant .
S.
No
Demographic variables Post test score
Chisquare
Pvalue
Levelof
significance
Normal Mild Moderate Severe
No. % No % No. % No %
9. TYPES OF STROKE
Hemorrhagic stroke 01 3.3 06 20 0 0 0 0 0.16 7.8
15
NS
Ischemic stroke 02 6.6 21 70 0 0 0 0
10 ANY OTHER TREATMENTS
Medical treatments 02 6.6 19 63.3 0 0 0 0 0.99 12.
592
NS
Surgical treatments 01 3.3 04 13.3 0 0 0 0
Physiotherapy 0 0 04 13.3 0 0 0 0

33. DISCUSSION
First objective was to assess the pre test level of
swallowing ability among cerebrovascular
accident patients with dysphagia.
• In pre test shows that, out of 30 patients, 26
(87%) had moderate dysphagia, 04 (13%) had
severe dysphagia.
• In post test shows that, out of 30 patients, in
pre test the overall mean is 12 with the
standard deviation of 1.8.

34. The second objective was to evaluate the
effectiveness of Chin Tuck Against Resistance
(CTAR) exercise in improvement of swallowing
ability among cerebrovascular accident patients
with dysphagia.
• In post test, 03 (10%) had normal swallowing
ability, 27 (90%) had mild dysphagia.
• In post test overall mean value is 19 with standard
deviation of 1.6.
• The paired “t” test score was 29, when compared
to table value (2.05) it was high. The result shows
there was a significant difference between pre and
post test CTAR Exercise score.

35. The third objective was to find out the association
between post test level of swallowing ability among
cerebrovascular patient and their selected
demographic variables.
• Statistically there is one strong significant association
between the post test level of swallowing ability among
cerebrovascular accident patients with dysphagia and
their demographical variables of residence.
• These findings suggested that the exercise was effective
in terms of reduction in the frequency, intensity,
duration, quality in the patients.
• The nurse must be alert to spend time to assess risk
factors for aspiration and develop nursing strategies to
prevent or reduce the incidence of dysphagia for
cerebrovascular accident patients.

36. RECOMMENDATIONS
Based on the research findings the following
recommendation can be made
• The same study can be replicated on a large number of
sample and also at different settings.
• A comparative study can be done between chin tuck
against exercise and other treatment modalities.
• A similar study can be done by using the experimental
design.
• This study can be clubbed with other forms of therapy
and to evaluate the effects of both.
• A similar study on chin tuck against resistance exercise
with different type of chin tuck against exercise.

37. CONCLUSION
Based on the findings of the study the following
conclusions were drawn.
• There was a significant difference between pre
and post test scores among cerebrovascular
accident patients with dysphagia.
• The chin tuck against resistance exercise was
more effective on cerebrovascular accident
patients with dysphagia.
• There was significant association between post
tests score of chin tuck against resistance exercise
with their demographic variables of residence

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