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Relationship between position sense and reposition errors according to the degree of upper crossed syndrome

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[Purpose] The purpose of this study was to compare reposition errors in subjects with upper crossed syndrome to examine the effects of upper crossed syndrome on position senses. [Subjects and Methods] A sample population of 60 subjects was randomly divided into three groups of 20: a normal group, a mild group, a moderate group. A cervical range of motion device was attached to the head of each subject using straps and the reposition errors of cervical flexion, extension, right lateral flexion, left lateral flexion, right rotation and left rotation were measured. [Results] The normal group showed smaller reposition errors than the mild group and the mild group showed smaller reposition errors than the moderate group but none of the differences among the three groups was significant. [Conclusion] Reposition errors increased in the order of the normal, mild, moderate group but the differences were not significant. In addition, the degree of the subjects’ postural misalignment was higher in the moderate than in the mild group. These results demonstrate that cervical spine position sense declines as postural misalignment becomes more severe.
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Relationship between position sense and
reposition errors according to the degree of
upper crossed syndrome
Seo-Yeung gu, MS, PT1), gak Hwangbo, PhD, PT1), Jeon-HYeong Lee, PhD, PT2)*
1) Department of Physical Therapy, College of Rehabilitation Science, Daegu University, Republic of Korea
2) Department of Physical Therapy, Daegu Health College: 15 Yeongsong-ro, Buk-gu, Daegu 41453,
Republic of Korea
Abstract. [Pur pose] The purpose of this study was to compare reposition errors in subjects with upper crossed
syndrome to examine the effects of upper crossed syndrome on position senses. [Subjects and Methods] A sample
population of 60 subjects was randomly divided into three groups of 20: a normal group, a mild group, a moderate
group. A cervical range of motion device was attached to the head of each subject using st raps and the reposition
errors of cervical exion, extension, r ight lateral exion, left lateral exion, right rotation and left rotation were
measured. [Results] The normal group showed smaller reposition errors than the mild group and the mild group
showed smaller reposition errors than the moderate group but none of the differences among the three groups was
signicant. [Conclusion] Reposition errors increased in the order of the normal, mild, moderate group but the differ-
ences were not signicant. In addition, the degree of the subjects’ postural misalignment was higher in the moderate
than in the mild group. These results demonstrate that cervical spine position sense declines as postural misalign-
ment becomes more severe.
Key words: Upper crossed syndrome, Position sense, Reposition error
(This article was submitted Oct. 13, 2015, and was accepted Oct. 30, 2015)
INTRODUCTION
Ofce workers or students who spend long periods in front of a computer or at a desk begin to adopt a forward head
posture, with the head forward of the spinal center line, when maintaining a normal spinal posture becomes difcult while
sitting for work1). A forward head posture causes mechanical stress on the neck. Due to the muscle imbalances resulting from
the stress, some muscles are inhibited and weakened and other muscles tend to lose tensility2). This muscle imbalance leads
to a vicious cycle that includes bent shoulders, shoulder rises, and abnormal postures of the shoulder blades. The vicious
cycle also leads to weakening of the muscles below the neck, such as the rhomboid muscles, the anterior serratus muscle, and
the lower trapezius muscle, and hardening of the antagonist muscles, such as the greater pectoral muscle, the upper trapezius
muscle, and the musculus levator scapulae, due to stiffeness. Janda dened this phenomenon as upper crossed syndrome
(UCS)3).
Proprioceptive senses are the senses used to control the positions and motions of the trunk and parts of the body in space4).
Proprioceptive senses related to the spatial recognition of the head require not only information from the vestibular organs
and visual information, but also proprioceptive sense information from the cervical spine5). Proprioceptive senses perform
two important roles in the neck: they provide information on posture and motion of the cervical spine to the central nervous
system, and they provide cervical reexes for stability and protection of the cervical spine6). Pathology, injuries, muscle fa-
tigue, and aging have been reported as causes of damage to cervical spine positional senses, and recent studies have reported
J. Phys. Ther. Sci. 28: 438 –4 41, 2016
*Corresponding author. Jeon-Hyeong Lee (E-mail: coordi18@naver.com)
©2016 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attr ibution Non-Commercial No Derivat ives (by-nc-nd)
License <http://creativecommons.org/licenses/by-nc-nd /4.0/>.
Original Article
The Journal of Physical Therapy Science The Journal of Physical Therapy Science
439
that position sense declines in patients with damage to the cervical spine or who complain of pain7, 8).
Therefore, the present study aimed to compare the reposition errors of subjects with upper crossed syndrome to examine
the effects of upper crossed syndrome on position sense.
SUBJECTS AND METHODS
In the present study, lateral photos were taken of 200 undergraduate students of D University. In total, 60 subjects (39
females, 21 males) were selected, based on the photos and they were divided into three groups (normal, mild, moderate) of
20 subjects per group based on the classication criteria of the experiment. None of the subjects had any musculoskeletal
system disease, pain, or neurologic symptoms, and all the subjects voluntarily agreed to participate in this study after receiv-
ing sufcient explanation about the study method and purpose. This study was approved by the Institutional Review Daegu
University. The subjects’ mean age was 22.3±0.33 years, their mean heights were 166.20±1.43 cm in the case of the normal
group, 167.30±1.28 cm in the case of the mild group and 167.40±1.73 cm in the case of the moderate group and their mean
weights were 59.05±1.73 kg in the case of the normal group, 62.70±2.24 kg in the case of the mild group and 59.60±2.31 kg
in the case of the moderate group.
All the subjects who participated in the experiments were instructed to sit on a chair with a backrest, to position their
ankle, knee, and hip joint at 90° and to face forward.
Photos were taken using smartphones to classify the degrees of the upper crossed syndrome, and the photos were analyzed
using Dartsh software (DFKOREA, Korea). The distances between the lateral center line of the shoulder and the lateral
center line of the ear were measured, and those with the lateral center line of the shoulder positioned less than 1 cm forward
from the lateral center line of the ear were classied as the normal group, those with the lateral center line of the shoulder
positioned 1–2.5 cm forward from the lateral center line of the ear were classied as the mild upper crossed syndrome group,
and those with the lateral center line of the shoulder positioned 2.5–5 cm forward from the lateral center line of the ear were
classied as the moderate upper crossed syndrome group9).
A cervical range of motion (C-ROM Basic, Performance Attainment Associates, USA) device was used to measure joint
position senses in the neck region. The C-ROM device was attached to the head of each subject using straps, and the subject
was instructed to wear an eye patch to block visual information to place the head in the neutral position, and to freely move
in various directions to relieve tension. When joint position senses were measured, external effects that might confuse the
subject’s proprioceptive information or cause sensory fatigue, such as noises and skin irritation, were blocked. For the
measurement, the C-ROM device was put on the head of the subject, and the shoulders of the subject were xed by the
experimenter so that the movements would not be affected by other parts of the trunk. The experiment was conducted by
instructing the subject to move the head to make a neck angle of 30°, which is 60% of the normal range of motion (ROM) of
the neck10). The subject was instructed to maintain the angle of 30° for three seconds in order to recognize the angle, return to
the neutral position and to make the angle of 30° again two times repeatedly without assistance, while taking a rest for three
seconds between measurements. Flexion was measured rst followed by extension, right lateral exion, left lateral exion,
right rotation, and left rotation.
To compare reposition errors among the three groups, differences from 30° as a reference value, which is 60% of the
full ROM, were measured as absolute values and compared using one-way ANOVA and the least signicant difference
(LSD) was used for post-hoc comparisons. The PASW statistics ver. 12.0 program was used for all statistical analyses with
a signicance level of α = 0.05.
RESU LTS
The subjects showed gradually bigger reposition errors in the order of the normal, the mild and the moderate group but
none of the differences between the three groups was signicant (p>0.05) (Table 1).
Tab le 1. The comparison of repositioning errors in cervical movement
Motion Normal Mild Moderate
Flexion(°) 3.10±0 .18 3.43± 0.32 3.93±0.66
Extension(°) 3.5 0 .18 4.30±0.50 4.6 0. 55
Right Bending(°) 2. 05±0.17 2.35±0.34 2.85± 0.36
Left Bending(°) 3.0 0 ±0.15 3.30±0.30 3.88±0.46
Right Rotat ion(°) 5.00±0.27 5.35±0. 20 5.85± 0.66
Left Rotation(°) 5.28±0.26 5.45±0. 22 5.65±0.44
Mean±standard error
Normal: nor mal group, Mild: mild group, Moderate: moderate group
J. Phys. Ther. Sci. Vol. 28, No. 2, 2016
440
DISCUSSION
Subjects with upper crossed syndrome generally sit or stand with stooped postures, compared to other subjects. In a study
of biomechanical changes in the trunk among sitting postures, Caneiro et al. reported that larger degrees of exion of the
dorsal spine and the lumbar spine appeared in stooped postures than in upright postures11), and the reason was that forward
postures with the chin positioned forward appear in stooped postures, putting the upper cervical spine into extension and the
lower cervical spine into exion12). In a study that examined the effects of different sitting postures on neck proprioceptive
senses, Jung et al. reported that position senses were poorer in stooped postures than in normal postures13) and Lee found that
subjects with severe forward head postures and larger reposition errors had poorer neck position senses14). The results of the
present study show that the mild group had smaller reposition errors than the moderate group but the differences were not
signicant; also, the degree of the subjects’ postural misalignment was higher in the moderate group than in the mild group.
Therefore, cervical spine position sense declined as postural misalignment became more severe. In a study of the relationship
between the habit of laterally bending the neck and position senses, Kim reported that position senses declined in those
who had incorrect postures15), and Bolton stated that as the longus colli muscle, a deep neck muscle, acts as a neck posture-
maintaining muscle, proper neck postures are maintained thanks to the information delivered from the muscle spindles
located in the longus colli16). Kirsch and Garza noted that in chronic neck pain patients, appropriate location information
could not be provided due to the atrophy of the longus colli muscle17). Therefore, from these results it can be inferred that if
such inappropriate postures are continuously maintained, the position senses of the cervical spine can decline further.
Jung et al. reported that the position of the head is recognized through appropriate proprioceptive senses, and information
for maintaining proper postures needs to be continuously provided13). Therefore, in relation to the postures of the cervical
spine, habits to develop correct posture are considered necessary to prevent the occurrence of damage or pain due to decline
in position sense.
Studies of the diverse causes of declines in neck position sense involving subjects from many age groups are considered
necessary.
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... Healthy girls were in a more favorable situation in proprioception variables of 45-and 80-degrees of shoulder external rotation in both right and left limbs than those with upper cross syndrome. With this respect, Gu et al. (2016) approved that as postural disharmony becomes more severe in upper cross syndrome cases, cervical spine proprioception decreases [48]. Shaghayeghfard et al. (2015) investigated the proprioception of neck in individuals with forward head and compared it with healthy ones, and their results expressed that those individuals with forward head have more errors in reconstructing some neck movements than healthy ones [49]. ...
... Healthy girls were in a more favorable situation in proprioception variables of 45-and 80-degrees of shoulder external rotation in both right and left limbs than those with upper cross syndrome. With this respect, Gu et al. (2016) approved that as postural disharmony becomes more severe in upper cross syndrome cases, cervical spine proprioception decreases [48]. Shaghayeghfard et al. (2015) investigated the proprioception of neck in individuals with forward head and compared it with healthy ones, and their results expressed that those individuals with forward head have more errors in reconstructing some neck movements than healthy ones [49]. ...
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Background and Aim Upper Crossed Syndrome (UCS) is a musculoskeletal disorder leading to postural deformities such as forward head posture (FHP), rounded shoulder posture (RSP) and hyper kyphosis. This abnormality has spread among people in the community due to modern lifestyle and excessive use of communication technologies. Therefore, the aim of this study was to investigate the effect of the eight -week comprehensive corrective exercises carried out in water on forward head, rounded shoulder, and hyper kyphosis as well as pain correction in men with UCS. Materials and Methods: In the current randomized controlled clinical trial, The minimum number of samples was determined using G.Power 3.1 sample size estimation software, 30 people. After initial screening 200 students using the posture screen, including a possible drop of 5% in the research process, 34 men with upper crossed syndrome, with mean age of 23 ± 0.80 years, weight 71.61 ± 2.2 kg, height of 171.75 ± 1.24 Cm And body mass index of 23.60 ±.67 Kg / m2), they were purposefully selected. These individuals were randomly divided into two groups: experimental (n = 17) and control (n = 17). The case group experienced comprehensive corrective exercises carried out in water for eight weeks and the control group received no intervention during this period. Before and after the intervention, measurements were performed to measure the forward head and rounded shoulder angles by imaging and angular analysis was done by AutoCAD software and kyphosis angle was determined by flexible ruler. Data were analyzed by SPSS software and the significance level was considered 0.05. Paired t-test was used to compare within the group and independent t-test was used to compare the mean differences between the groups. Results: The results showed that the experimental group had significant improvement in in terms of the kyphosis (P= 0.001), FHP (P=0.001) and RSP (P=0.001). Conclusion: According to the results, Eight weeks of corrective exercises in the water environment can be significantly effective in reducing the angle of the head forward, round shoulder and hyper kyphosis in people with upper cross syndrome, and it can be recommended to specialists as a treatment.
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Objective To observe the clinical effect of combined acupuncture and kinesiotherapy on upper cross syndrome (UCS) by a parallel randomized clinical trial. Methods A total of 45 patients with UCS were recruited from the outpatients of Acupuncture-Moxibustion, Tuina and Rehabilitation Department of the First Affiliated Hospital of Hunan University of Chinese Medicine, the students of Hunan University of Chinese Medicine and the patients from the nearby communities in accordance with the inclusion criteria. Using the random number table method, they were divided into a combined treatment group (acupuncture plus kinesiotherapy, 23 cases) and a simple kinesiotherapy group (22 patients). Treatment for 4 weeks was one course, and two consecutive courses were required. The visual analog scale (VAS) score, the score of the assessment scale for cervical spondylosis, the value of surface electromyography (root mean square, RMS), and the cervical curvature value were used in the evaluation. The allocation scheme was concealed from the outcome assessors. Results The data from 23 cases of the combined treatment group and 22 cases of the simple kinesiotherapy group were analyzed. Before treatment, the differences were not statistically significant in the general conditions, VAS score, assessment score of cervical spondylosis, cervical curvature value, and RMS in UCS patients between the two groups (all P > 0.05). After treatment, the VAS score was reduced compared with that before treatment in both groups (all P < 0.05). In two courses of treatment, the VAS score decreased as compared with that in one course of treatment in both groups (both P < 0.05), and the VAS score in the combined treatment group decreased more obviously after each course of treatment (both P < 0.05). The RMS decreased compared with that before treatment in each group (both P < 0.05), and the decrease in the combined treatment group was more obvious (P < 0.05). After treatment of each course, the assessment score was all increased as compared with that before treatment in two groups (all P < 0.05). In two courses of treatment, the assessment score was increased as compared with that in one course of treatment in both groups (both P < 0.05), and the score in the combined treatment group was increased more obviously in the two courses of treatment (P < 0.05). Regarding either the intra-group comparison or the inter-group comparison before and after treatment, the differences were not statistically significant (all P > 0.05), suggesting no obvious improvement of cervical curvature in the two courses of treatment in patients with UCS. However, cervical curvature tended to improve in the combined treatment group. The total effective rate was significantly different between the two groups (P < 0.05), indicating that the total effective rate in the combined treatment group was better than that in the simple kinesiotherapy group.No any adverse reactions occurred. Conclusion Combined treatment with acupuncture, kinesiotherapy, and kinesiotherapy alleviated pain, relieved the symptoms and physical signs, and improved the daily movement of the patients. However, the combined treatment of acupuncture and kinesiotherapy had a much better effect on UCS.
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To determine the frequency of upper cross syndrome and its association with prolonged sitting postures and to determine the functional status of upper extremity affected by prolong sitting among young population. METHODS: It was an analytical cross sectional study, conducted in Fatima Memorial College of Medicine and dentistry, Lahore from 18 October, 2017 to 30 January, 2018. Reed co postural assessment scale score was used for the postural assessment, upper limb functional index (ULFI) was used to inquire about the participant current upper extremity functional status in a variety of activities. RESULTS: Out of 165 participants who had 6 to 8 of sitting 15.75% had moderate level of difficulty and out of 150 participants who had 8 to 10 hours of sitting 26.66% had moderate level of difficulty, so significant association was found between sitting hours and upper extremity functional status with p=0.00. Postural analysis of head position, neck position, and upper back has also showed that there is significant association with p value =.000 (< 0.05) between sitting hours and postural changes, as increasing sitting hours cause increased postural changes. CONCLUSION: In the light of these results, it is concluded that prolonged sitting hours are associated with upper cross syndrome and change in upper extremity functional status, so certain strategies could be suggested for the workstations or the individuals, involves in prolong sitting.
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The purpose of this study was to investigate the influence of different sitting postures on range of motion, strength and proprioceptive sense of neck. Fifteen healthy university students participated in the study. Depending on upright sitting position and slump sitting position, range of motion and joint position sense were measured by using Dualer IQ. Also, the maximum isometric strength and force sense were measured by using linear force. As a result, we found that the maximum angle of neck extension and the maximum isometric strength at flexion were significantly higher in upright posture than in slump posture. Also, the maximum angle of neck flexion and the maximum isometric strength at extension were higher in slump posture than in upright posture. According to the result, proper proprioception can have an beneficial effect on postural revision of neck and body by providing the information that cognize the position of head through and sustain upright posture.
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[Purpose] The purpose of this study was to compare cervical repositioning errors according to smartphone addiction grades of adults in their 20s. [Subjects and Methods] A survey of smartphone addiction was conducted of 200 adults. Based on the survey results, 30 subjects were chosen to participate in this study, and they were divided into three groups of 10; a Normal Group, a Moderate Addiction Group, and a Severe Addiction Group. After attaching a C-ROM, we measured the cervical repositioning errors of flexion, extension, right lateral flexion and left lateral flexion. [Results] Significant differences in the cervical repositioning errors of flexion, extension, and right and left lateral flexion were found among the Normal Group, Moderate Addiction Group, and Severe Addiction Group. In particular, the Severe Addiction Group showed the largest errors. [Conclusion] The result indicates that as smartphone addiction becomes more severe, a person is more likely to show impaired proprioception, as well as impaired ability to recognize the right posture. Thus, musculoskeletal problems due to smartphone addiction should be resolved through social cognition and intervention, and physical therapeutic education and intervention to educate people about correct postures.
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To identify if there were differences in the cervical biomechanics in preadolescents who had recurrent neck pain and/or headaches and those who did not. A controlled comparison study with a convenience sample of 131 students (10-13 years old) was performed. A questionnaire placed students in the no pain group or in the neck pain/headache group. A physical examination was performed by a doctor of chiropractic to establish head posture, active cervical rotation, passive cervical joint functioning, and muscle impairment. The unpaired t test and the chi(2) test were used to test for differences between the 2 groups, and data were analyzed using SPSS 15 (SPSS Inc, Chicago, Ill). Forty percent of the children (n = 52) reported neck pain and/or recurrent headache. Neck pain and/or headache were not associated with forward head posture, impaired functioning in cervical paraspinal muscles, and joint dysfunction in the upper and middle cervical spine in these subjects. However, joint dysfunction in the lower cervical spine was significantly associated with neck pain and/or headache in these preadolescents. Most of the students had nonsymptomatic biomechanical dysfunction of the upper cervical spine. There was a wide variation between parental report and the child's self-report of trauma history and neck pain and/or headache prevalence. In this study, the physical examination findings between preadolescents with neck pain and/or headaches and those who were symptom free differed significantly in one of the parameters measured. Cervical joint dysfunction was a significant finding among those preadolescents complaining of neck pain and/or headache as compared to those who did not.
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To determine whether vestibular or cervical proprioceptive information influence the cervicocephalic relocation test to the neutral head position, by comparing head repositioning errors obtained in asymptomatic, unimpaired control subjects with those obtained in bilateral labyrinthine-defective patients and chronic, nontraumatic neck pain patients. A group-comparison study. University medical bioengineering laboratory. Labyrinthine-defective patients (n=7; mean age+/-SD, 67+/-15 y), nontraumatic neck pain patients (n=7; 56+/-9 y), and asymptomatic, unimpaired control subjects (n=7; 64+/-12 y). Participants were asked to relocate the head on the trunk, as accurately as possible, after full active cervical rotation to the left and right sides. Ten trials were performed for each rotation side. Absolute and variable errors were used to assess accuracy and consistency of the repositioning, respectively. No significant difference in repositioning errors was observed between labyrinthine-defective patients and control subjects, whereas nontraumatic neck pain patients demonstrated significantly increased absolute errors in horizontal and global components and higher variable errors in horizontal component. These findings suggest that the vestibular system is not involved in the performance of the cervicocephalic relocation test to neutral head position, and further support this test as a measure of cervical proprioceptive acuity.
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The cervibrachial syndromes related to work form an important group of rheumatic diseases. Surveys of rheumatic complaints in different occupations have been made for half a century. In these studies the cervicobrachial pain syndromes are preceded only by back diseases as a cause of occupational rheumatism. The nomenclature of rheumatic diseases is difficult to systematize, and the differences in diagnostic criteria are partly reflected in the results of field surveys. Moreover, official statistics based on the International Classification of Diseases are only of limited value when the socioeconomic burden of these diseases is being estimated. What is also confusing is the role of work in the etiology or symptomatology of rheumatic diseases. Obviously there is no universal cause, such as 'wear and tear' or 'usage,' for the common rheumatic syndromes. The role of occupational medicine today is to detect and report the defined patterns of occupational overuse associated with defined clinical syndromes. In the present review the cervicobrachial syndromes are divided into four entities, namely, the cervical syndrome, the tension neck syndrome, the humeral tendinitises, and the thoracic outlet syndrome. Each of these syndromes is discussed separately, and their incidence, etiology, pathogenesis and clinical signs are considered from an occupational point of view. The frozen shoulder and acromioclavicular syndromes have not been included because of the scant relevant literature focusing on the occupational aspects of these entities.