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The effectiveness of a comprehensive corrective exercises program and subsequent detraining on alignment, muscle activation, and movement pattern in men with upper crossed syndrome: protocol for a parallel-group randomized controlled trial

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The effectiveness of a comprehensive corrective exercises program and subsequent detraining on alignment, muscle activation, and movement pattern in men with upper crossed syndrome: protocol for a parallel-group randomized controlled trial

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Background: Upper crossed syndrome (UCS) refers to specific altered muscle activation and changed movement patterns along with some postural deviations in the upper quarter of the body. This syndrome might contribute to the dysfunction of the cervicothoracic and glenohumeral joints. Objectives: The present study will aim to investigate the effectiveness of a comprehensive corrective exercises program (CCEP) and subsequent detraining on alignment, muscle activation and movement pattern in men with UCS. Methods/design: This is a parallel-group randomized controlled trial. Participants will be 22 men aged 18 to 28 years who are suffering from UCS. Participants in the intervention group will conduct CCEP (three times a week for 8 weeks), followed by 4 weeks of detraining. The control group will do their daily activities. Participants will be randomized (1:1) into the intervention or the control group. The primary outcome will be upper trapezius activations. Secondary outcomes consist of electromyography of middle and lower trapezius and serratus anterior muscles, scapular dyskinesis test, forward head and shoulder angles, thoracic kyphosis angle, and neck flexion pattern test. Discussion: We propose to evaluate the effectiveness of a randomized controlled trial of a CCEP in men with UCS on their alignment, selected muscle activations, and relevant movement patterns. Results from our trial may provide new insights into the effects of exercise not only on the alignment but also on muscle activation and movement patterns that are important outcomes for people with postural malalignments and, if successful, could assist therapists in evidence-based clinical decision-making. Trial registration: Iranian Registry of Clinical Trials, IRCT20181004041232N1. Registered on 26 October 2018.
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S T U D Y P R O T O C O L Open Access
The effectiveness of a comprehensive
corrective exercises program and
subsequent detraining on alignment,
muscle activation, and movement pattern
in men with upper crossed syndrome:
protocol for a parallel-group randomized
controlled trial
Mohammad Bayattork
1,2
, Foad Seidi
1*
, Hooman Minoonejad
1
, Lars Louis Andersen
3,4
and Phil Page
5
Abstract
Background: Upper crossed syndrome (UCS) refers to specific altered muscle activation and changed movement
patterns along with some postural deviations in the upper quarter of the body. This syndrome might contribute to
the dysfunction of the cervicothoracic and glenohumeral joints.
Objectives: The present study will aim to investigate the effectiveness of a comprehensive corrective exercises
program (CCEP) and subsequent detraining on alignment, muscle activation and movement pattern in men with
UCS.
Methods/design: This is a parallel-group randomized controlled trial. Participants will be 22 men aged 18 to 28
years who are suffering from UCS. Participants in the intervention group will conduct CCEP (three times a week for
8 weeks), followed by 4 weeks of detraining. The control group will do their daily activities. Participants will be
randomized (1:1) into the intervention or the control group. The primary outcome will be upper trapezius
activations. Secondary outcomes consist of electromyography of middle and lower trapezius and serratus anterior
muscles, scapular dyskinesis test, forward head and shoulder angles, thoracic kyphosis angle, and neck flexion
pattern test.
Discussion: We propose to evaluate the effectiveness of a randomized controlled trial of a CCEP in men with UCS
on their alignment, selected muscle activations, and relevant movement patterns. Results from our trial may provide
new insights into the effects of exercise not only on the alignment but also on muscle activation and movement
patterns that are important outcomes for people with postural malalignments and, if successful, could assist
therapists in evidence-based clinical decision-making.
Trial registration: Iranian Registry of Clinical Trials, IRCT20181004041232N1. Registered on 26 October 2018.
Keywords: Corrective exercises, Alignment, Muscle activation, Movement pattern, UCS
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: foadseidi@ut.ac.ir
1
Health and Sports Medicine Department, Faculty of Physical Education and
Sport Sciences, University of Tehran, Tehran, Iran
Full list of author information is available at the end of the article
Bayattork et al. Trials (2020) 21:255
https://doi.org/10.1186/s13063-020-4159-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Most people will see a medical practitioner or an-
other health care provider at least once in their life-
time because of neck, shoulder and back pain [1,2].
At a societal level, these pains are also responsible for
substantial costs, including healthcare expenditure,
disability insurance, and work absenteeism [3]. Previ-
ous studies showed that these pains might be associ-
ated with abnormal alignments [4,5]. One of these
malalignments is the upper crossed syndrome (UCS),
which was defined as a muscular imbalance pattern
by Vladimir Janda MD (19232002) [6]. UCS refers
to specific altered muscle activation and movement
patterns along with some postural deviations [7]. Al-
terations in muscle activation include overactivity of
the upper trapezius, levator scapula, and pectorals
muscles and underactivity of the deep cervical flexors,
middle and lower trapezius, and serratus anterior [8].
Due to kinetic and muscular chains, there are altered
scapular movement patterns (scapular dyskinesis) and
specific postural changes, including forward head and
shoulder posture and increased thoracic kyphosis [7,
9]. These changes can lead to reduction in the stabil-
ity of the glenohumeral joint and to various
musculoskeletal symptoms in the head, neck, and
shoulder [7,8,10].
Over recent decades, therapists have been seeking
to design appropriate exercises to correct musculo-
skeletal malalignments mainly through structural and
functional approaches [1113]. In the traditional
structural approach, the changes observed in mala-
lignments such as in UCS are attributed to biomech-
anicsandarepresumedtoleadtoadjustmentsinthe
length and strength of local muscles [11,14]. This
may account for the stretching of short muscles and
strengthening of weakened muscles at the site of the
problem in the correction phase, while ignoring other
related malalignments [14]. Interestingly, despite the
popularity of this method, very little research has
been conducted based on this theory [15]. Further-
more, some review studies have questioned the effect-
iveness of strengthening and stretching exercises to
improve postural disorders [16,17].
In contrast, the functional (neurological) approach
to musculoskeletal problems is based on the inter-
action of the central and peripheral nervous systems,
and the involvement of the muscular and skeletal
structures in producing and controlling motion [6,18,
19]. In this functional approach, the musculoskeletal
problems are attributed to the role of muscles in
motor function; furthermore, changes in the align-
ment result not only from changes in muscle length
and strength but also from more important changes
in muscle neuromuscular factors, such as muscle
recruitments [13,20]. In fact, the motor control unit
maychangethemuscleactivationstrategyfortem-
porary stabilization due to the presence of dysfunc-
tion. These changes in motor recruitment will alter
the muscular balance, movement patterns, and even-
tually the motor program [12]. Similarly, Hodges
et al. noted that motor control interventions require
tailoring to each individuals posture, muscle activa-
tion, and movement pattern [21]. However, this the-
ory has not been tested in practice for the prevention
and treatment of musculoskeletal malalignments.
Hence, for the assessment of UCS, the alignment
and its side effects are often evaluated, such as in-
crease in thoracic kyphosis or forward head angles,
while less attention has been paid to the keystone,
i.e., the scapulae, and the relevant altered muscle acti-
vation and movement patterns [22]. In this regard,
many researchers and therapists have only evaluated
one of the affected regions, such as head, shoulders,
or spine, separately and reported a degree of postural
deviation regardless of other relevant malalignments
and patterns of the muscle activation and related
movement patterns, such as scapulohumeral rhythm
or neck flexion [2325]. In addition, the design and
implementation of the training protocol are based on
the traditional structural approach, in which stretch-
ing exercises for short muscles and strengthening ex-
ercises for weak muscles are prescribed at the site of
malalignment [22,24], while the neuromuscular fac-
tors and related movement patterns may not be con-
sidered. To the best of our knowledge, no studies
identifying and correcting UCS have considered the
three components of alignment, movement pattern,
and muscle activity in both assessment and correction
processes.
Study objectives
The primary aim of the present study is to evaluate
the effectiveness of a comprehensive corrective exer-
ciseprogram(CCEP)inyoungmenwithUCSfor8
weeks, as measured by alignment (position of the
scapula, head and neck, shoulder, and thoracic spine),
electromyography activity of selected muscles (upper,
middle and lower trapezius, serratus anterior), and
specific movement patterns (scapulohumeral rhythm
and neck flexion). A secondary aim is to evaluate the
effects of the program after 4 weeks of detraining
after the intervention.
Methods/design
Study design
This is a parallel-group randomized controlled trial
comparing an intervention group receiving an 8-week
CCEP followed by 4 weeks of detraining to a control
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group who will only do their daily activities. The
study will be performed at the Laboratory of Health
and Sports Medicine Department, University of
Tehran, Tehran, Iran. Initially, participants will take
part in the baseline assessment process. They will
then receive the intervention for 8 weeks. After the
end of the intervention phase, all the measurements
will be repeated. Finally, a follow-up assessment will
be performed after a 4-week detraining period. The
study schedule is presented in Table 1and a flow
diagram is shown in Fig. 1. The study protocol is re-
ported in accordance with the SPIRIT guideline.
Ethical aspects
Before starting the project, all participants will be
asked to complete and sign an informed consent
form. Ethics approval was obtained on August 28, 2017,
from the Ethics Committee on Research at University of
Tehran, Iran (IR.UT.REC.1395026). The protocol was ap-
proved at the Iranian Registry of Clinical Trials on 2018-
10-26 (IRCT20181004041232N1).
Study participants and eligibility criteria
The participants consist of 24 men with UCS aged 18
to 28 years. They will be recruited from the students
of the University of Tehran, Iran, through advertise-
ments on bulletin boards. They will be screened pri-
marily by observation for three main factors related
to UCS, including altered alignment, muscle
activation, and movement patterns. Since the scapulae
are the keystone in UCS, participants who have any
abnormality in the position and rhythm of the scap-
ula, as measured by the scapular dyskinesis test, will
be recruited. In addition, they will be assessed for
presenting any postural changes such as forward head
(44°), round shoulder (49°), or excessive thoracic
kyphosis (42°) as measured by photogrammetry and
flexicurve, respectively [15]. Also, to ensure any
change in muscle activation is related to postural
changes, some confirmatory tests, including muscle
length tests for upper trapezius and pectoral muscles
as well as muscle strength tests for middle and lower
trapezius and deep cervical flexor, will be used. Indi-
viduals will be excluded from the research process if
they do extra physical activity and sports that may
affect the outcomes of the research, have any visible
malalignment in the pelvis and lower extremities,
have a history of fracture, surgery, or joint diseases in
the spine, shoulder and pelvis, have a rotation greater
than 5° on the forward bending test because of scoli-
osis [15], or have a bodyweight outside the normal
range (body mass index between 18 and 25) [23].
Randomization
Participants will be randomized using computer-
generated block randomization in a 1:1 ratio, followed
by a concealed allocation through opening sequentially
numbered, opaque and sealed envelopes; a card inside
Table 1 Schedule of the study
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will indicate the group into which the participant will
randomly be allocated, i.e., the intervention or the con-
trol group. Participants can discontinue the project at
any time. However, all efforts will be made to avoid
missing data. The specific way to deal with missing data
will be determined at a data review meeting before start-
ing statistical analyses.
Comprehensive approach
The comprehensive approach (Fig. 2), which is a new
approach to corrective exercises [15], takes advantage
of the strengths and weaknesses of traditional ap-
proaches to achieve the best outcome in correcting
musculoskeletal malalignments. It was initiated in
2014 by Seidi et al., who compared the efficacy of
comprehensive and traditional corrective exercise pro-
grams on the kyphosis angle [15]. The general pur-
pose of this approach is to pay attention to
alignment, muscle activation, and movement pattern
simultaneously across the whole body rather than at
just a single site during both the assessment and cor-
rection phases.
Intervention
An 8-week CCEP will be structured to include three
phases. In the initial phase of the exercise program,
the participants will become cognizant of the purpose
and the quality of the exercises. This is characterized
as voluntary control of exercise, requiring cortical
regulation of movement and a lot of concentration on the
part of the participants [12]. Participants will be asked to
focus only on the scapular muscles, i.e., an internal focus
[26] while their alignment is corrected passively. So, the
exercises will be executed in non-weight bearing positions
and the participants only try to contract underactive mus-
cles isometrically and relax overactive muscles around the
scapula for normalization of scapular position and motion
[27,28]. The participants will be instructed to reproduce
this orientation of scapula actively using auditory (from
therapist) and kinesthetic cues such as palpation [28].
Once a participant regains sufficient control over scapular
muscles, he will focus externally on it and turn the
internal focus of attention to correcting proximal seg-
ments through chin tuck, retraction of shoulders, and
straightening the upper thoracic spine [29]. Then, he
will do the exercises in different weight-bearing posi-
tions, and after restoring muscle balance in the static
conditions, he will try to add upper extremity
movements in various training positions. Also, the re-
spiratory pattern of participants will be controlled
during this phase and necessary feedback will be pro-
vided [13]. Since the quality of exercises is highly im-
portant in this phase, the participants should not feel
fatigued while doing the exercises because fatigue
Fig. 1 Study flowchart
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may alter optimal muscle activations and movement
patterns [30].
Once the participants can contract the appropriate
muscles in a correct alignment during the best move-
ment pattern, they should be able to maintain this for
a long time. This goal will be addressed in the im-
provement phase when necessary tissue adaptations
occur by increasing the load of exercises [31,32]. Pla-
cing the participants in weight-bearing positions and
using some tools such as training balls and Thera-
Bands will reinforce their abilities gradually. During
this phase, the participants will only focus on the goal
of exercises (external focus) [29]. Moreover, because
UCS is representative of underlying potential sensori-
motor dysfunction, some functional balance exercises
will be included [12]. The frequency and intensity of
the exercises will increase progressively during the
study, provided that participants can demonstrate
good-quality movement. In the final phase, i.e., the
maintenance phase, the participants will try to
maintain the training adaptations [32]. All exercises
will be performed under the supervision of a correct-
ive exercise specialist. The participants will not con-
duct any extra exercises at home. However, they will
be asked to avoid sustaining poor posture. More de-
tails about the intervention protocol are presented in
Appendix 1. The control group will be asked to do
their ordinary daily activities and not to participate in
any exercise programs. After the study is completed,
the control group will undergo the exercise interven-
tion protocol for ethical reasons.
Outcome measures
All outcome measurements will be performed by the
main researcher at baseline, 8 weeks (after interven-
tion), and 12 weeks (follow-up). Demographic infor-
mation (i.e., sex, age, body mass index) will be
measured before the intervention.
Fig. 2 Comprehensive approach flowchart
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Outcome measures
Upper trapezius activation (measured with surface
electromyography) is the primary outcome measure.
Secondary outcomes include electromyography mea-
surements of middle and lower trapezius and serratus
anterior muscles, scapular dyskinesis, forward head
and shoulder angles, thoracic kyphosis angle, and
neck flexion pattern.
Electromyography measurements Surface electro-
myography of the scapular stabilizer muscles (including
upper, middle, lower trapezius, and serratus anterior)
will be performed using an ME-6000 Megawin. The
participants will execute humeral abduction without
resistance in three phases (concentric, isometric, and
eccentric) lasting for 3 s each. They will already have
been trained to move correctly and at the right speed
so that they can perform the movement five times;
rest time is 3 s between movements. Disposable Ag-
AgCl electrodes with a diameter of 2 cm and a 2 cm
spacing between two poles of electrodes will be used
and data will be recorded at a frequency of 1000 Hz.
The location of the electrodes will be determined
using the SENIAM protocol and based on valid scien-
tific papers [33,34]. The maximum voluntary isomet-
ric contraction (MVIC) will be recorded to normalize
the signals. More details about the location of the
electrodes and MVIC positions are presented in
Appendix 2. The data from the mean square root
(RMS) will be used in the process of measuring
muscle activation. To determine the onset of muscle
activity, only the concentric phase of the motion will
be used and it will be based on the onset of the del-
toid muscle. Moreover, the onset of the activity will
be from the point where the level of muscle activity
reaches two standard deviations above the rest of the
muscle activity [34].
Scapular dyskinesis The current recommendation for
clinical assessment based on a prior consensus meet-
ing is the use of the dynamic scapular dyskinesis test
according to the procedure described by McClure
et al. [35]. The position and motion of scapula are
characterized by dyskinesis as a yes(presence of de-
viation or dysrhythmia/asymmetry bilaterally) or no
(no presence). This method has been shown to be re-
liable among observers and has acceptable clinical
utility [35,36].
Forward head and shoulder angles The angle of the
head and the shoulder will be measured using
photogrammetry according to the procedure described by
Seidi et al. [15]. The validity and reliability of this method
have been established in previous studies [37,38].
Thoracic kyphosis angle To measure the static align-
ment of the thoracic spine, the flexicurve method will be
used, which is a well-established, valid, and reliable tech-
nique [39,40]. A detailed description of the procedure
can be found in previous studies [15,23].
Neck flexion pattern test The participants will lie su-
pine with knees bent. They will then be instructed to lift
the head and look at their toes. Normal movement pro-
duces a smooth reversal of the normal cervical lordosis,
keeping the chin tucked. Abnormal movement is com-
pensated by the tightness of the SCM, producing an
early protraction of the chin directly upward at the be-
ginning of the motion [8].
Sample size
The sample size was calculated using the G*Power soft-
ware (G*Power, version 3.0.10, Germany). It was based
on a pilot test of seven participants, and on the assump-
tion that a 10% difference in muscle activity [34]andan
11° difference in kyphosis angle [41] between groups
would constitute clinically meaningful differences. It was
calculated that a sample consisting of at least 18 partici-
pants would suffice to obtain 80% power with d = 0.80
effect size, and a confidence interval of 0.95. It should be
noted that the effect size was reported in the previous
study which compared scapular muscle activity between
the interventions and control groups. Effect sizes ranged
from 0.6 to 0.9 for the EMG amplitude and onset [42].
Since a few participants may drop out of the interven-
tion studies, we will include 24 (assuming a drop-out
rate of approximately 25%).
Statistical method and analysis
Assessments of statistical procedures will be performed
using IBM SPSS version 20 for Windows (SPSS Inc.,
Chicago, IL, USA). All variables will be reported using
the descriptive statistic (mean, standard deviation).
Shapiro-Wilk test will be used to assess the normality of
data. Repeated measures ANOVA will be used to com-
pare the means. If mean difference is significant, then
the Bonferroni-adjusted post-hoc test will be calculated.
The independent t-test will also be used for comparison
between groups. Finally, the effect size will be calculated
for the magnitude of the difference using the Cohen
method. The significance level will be set at p< 0.05.
Discussion
We propose to evaluate the effectiveness of a random-
ized controlled trial of a CCEP in a group of men aged
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18 to 28 years with UCS in terms of their alignment, se-
lected muscle activation, and relevant movement
patterns.
Clinicians believe that it is important to quantify
head, shoulder, scapulae, and spinal posture behavior
as they influence and are influenced by many bio-
mechanical, motor control, and performance variables
[43]. It has been assumed that exercise can correct
postural malalignment, but an earlier review found lit-
tle evidence to support this assumption [17]. More-
over, despite the widespread inclusion of postural
correction in exercise interventions, there are limited
empirical data to support its effectiveness and little is
known about the most effective exercise interventions
[24]. As already mentioned, it seems the most import-
ant reason is the adherence to the traditional struc-
tural approach in the previous studies. We want to
conduct a randomized controlled trial based on the
comprehensive approach which is adequately powered
and utilizes validated outcome measurements of UCS
to investigate the effects of the CCEP on both our
primary and secondary outcomes. If the CCEP results
in changing the alignment, muscle activation, and
movement pattern, or all three, we will examine the
pathways of change to determine whether changes in
thealignment,muscleactivation, or movement pat-
tern can account for the change in the UCS symp-
toms. Furthermore, if we find out that the CCEP can
improve a postural malalignment like in UCS, this
evidence could enable practitioners to recommend
early intervention for UCS to prevent or delay UCS-
associated consequences. Therefore, various experts in
the field of corrective exercises and physical therapy,
equipped with the knowledge on these changes, can
identify people with UCS and also adopt appropriate
therapeutic strategies to correct it and prevent the oc-
currence of secondary consequences.
Our study has some limitations including the re-
cruitment of only men 18 to 28 years of age. There-
fore, the results of this study will not be generalizable
to all people (e.g., women or men aged 28 years)
with UCS. Another limitation is that this study is not
a double-blind design since it is not possible, as is
the case with most exercise trials.
The results of our study will be presented at scien-
tific conferences and published in academic journals
to ensure that our study will inform therapists in
practice and prove beneficial to patient care. Our goal
is to conduct a clinical trial that will provide thera-
pists with evidence of the efficacy of the CCEP on
thekeystoneandthesideeffectsofUCS.Previoustri-
als have often used only assessment of the alignment
to investigate the improvement of a malalignment.
However, we are focusing on alignment, muscle
activation, and movement pattern simultaneously
based on the comprehensive approach. Therefore, if
our exercise intervention proves successful, our ap-
proach to improving UCS could represent a funda-
mental paradigm shift in exercise intervention
strategies to improve postural malalignments and
their consequences. Results from our trial may pro-
vide new insights into the effects of exercise not only
on alignment but also on muscle activation and
movement pattern, which are important outcomes for
people with postural malalignments and, if successful,
it could assist practitioners in individualized clinical
decision-making. However, our results may have a
limited transferability to all people and thus may be
valid only for men.
Trial status
This trial was registered on 2018-10-26 (registration
number IRCT20181004041232N1, protocol version
number 34266, https://en.irct.ir/user/trial/34266/view).
The trial is currently in the stage of recruiting
patients. The first patient was included on 2019-02-
01. To date, ten patients have been included. The
recruitment will be completed on approximately
2019-07-01.
Appendix 1
Comprehensive corrective exercise program
The duration of the exercise protocol is 8 weeks, with
three sessions per week, and each session will be about
an hour. Each exercise session begins with 10 min of
warm-up activity and ends with 5 min of cool-down. Se-
lected exercises are designed in three phases: initial, im-
provement, and maintenance [35].
Initial phase exercises
The initial phase exercises (Fig. 3) include laying supine
on a foam roll in three different arm abduction angles (ex-
ercise 1AC), side-lying external rotation (exercise 2),
side-lying forward flexion (exercise 3), standing diagonal
flexion (exercise 4), and military press (exercise 5). Partici-
pants with less ability can do exercises 4 and 5 in a sitting
position. Once a participant regains muscle balance in the
static conditions, he will try to add upper extremity move-
ments in exercise positions. Exercises progress in fre-
quency and intensity during this phase, as long as
participants are able to demonstrate good quality move-
ment. The initial phase duration is 2 weeks and the exer-
cises will be performed for seven sets of 10-s hold to ten
sets of 15-s hold.
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Improvement phase exercises
The goal of the improvement phase is to create the
necessary tissue adaptations in the participant. There-
fore, during this phase Thera-Bands, weights, and
training balls will be used. Improvement phase exer-
cises (Fig. 4) include side-lying external rotation with
adumbbell(exercise6),side-lyingforwardflexion
with a dumbbell (exercise 7), standing diagonal
flexion with a dumbbell (exercise 8), standing external
rotation with Thera-band (exercise 9), standing diag-
onal flexion with Thera-band (exercise 10), abduction
in sitting on a training ball (exercise 11), lying prone
V, T, and W exercises (exercise 12), and abduction in
standing on a balance board (exercise 13). Exercises
are progressed by considering individual characteris-
tics of each participant and by observing the overload
principle and the progression in the number of repe-
titions of each set during the 4 weeks of the improve-
ment phase. The exercises will be performed from
five sets of ten repetitions to six sets of 15
repetitions.
Maintenance phase exercises: The exercises are the
same as in the improvement phase without any progres-
sion in intensity and frequency. The maintenance phase
duration is 2 weeks.
Fig. 3 The initial phase exercises
Fig. 4 The improvement phase exercises
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Acknowledgments
We are thankful to the participants for their participation. We also
acknowledge the dedicated research professionals who contribute to the
intervention and assessment of the participants in this study.
Dissemination
The study results will be published in peer-reviewed journals.
Authorscontributions
MBT and FS designed the trial. MBT, FS, and HM participated in trial
registration, evaluation, and monitoring. MBT performed the exercises. LLA
and PP have contributed to drafting the manuscript and revising it critically
for important intellectual content. MBT, HM, LLA, and PP participated in the
design of the statistical analysis. All authors contributed to the refinement of
the study protocol and approved the final manuscript.
Funding
The authors state no external or internal funding involved.
Availability of data and materials
The authors aim to make the datasets supporting the results and
conclusions of this study available as supplementary files in future published
articles.
Ethics approval and consent to participate
Ethics approval was obtained on August 28, 2017, from the Ethics
Committee on Research in University of Tehran, Iran (IR.UT.REC.1395026).
Before starting the project, all participants will be asked to complete the
written consent form.
Consent for publication
Written informed consent was obtained from the person for publication of
his accompanying images in this manuscript.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Health and Sports Medicine Department, Faculty of Physical Education and
Sport Sciences, University of Tehran, Tehran, Iran.
2
Sport Sciences and
Physical Education, Faculty of Humanities Science, University of Hormozgan,
Bandar Abbas, Iran.
3
National Research Centre for the Working Environment,
Copenhagen, Denmark.
4
Sport Sciences, Department of Health Science and
Technology, Aalborg University, DK-9220 Aalborg, Denmark.
5
Performance
Health, Baton Rouge, Louisiana, USA.
Received: 25 May 2019 Accepted: 11 February 2020
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Appendix 2
Table 2 The locations of electrodes and MVIC positions
Muscle Electrode location MVIC position
Upper trapezius The halfway point between the spinous process of the seventh
cervical vertebra and the acromion
In a sitting position with abduction at 90°
Middle trapezius The halfway point between the scapular medial border and the T3 In a prone position with horizontal abduction at
90° and external rotation
Lower trapezius At 2/3 on the line from the trigonum spinea to the T8 In a prone position with horizontal abduction in
120° in line with the fibers of the muscle and the
thumb pointing upward
Serratus anterior In the mid-axillary line over the fifth rib In a sitting position with maximum resistance
given to upward rotation of the scapula with the
shoulder flexed
Middle deltoid The halfway point of the acromion and the deltoid tuberosity In a sitting position with abduction at 90°
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... In other words, the lateral and posterior fossae affect the length change in these muscles mechanically in gait pressure (44,45). Similarly, patelle is the cause of femoral pain (44,(46)(47)(48). ...
... Thus, the energy in postural muscular activities, which is further evaluation, is eccentric (46). Overactive muscle strength or less active muscle strength, upper cross syndrome, and lower cross syndrome limitation within the whole body structure (47). The limitation is the forward head-rounded shoulder-and cervical kyphosis arising from the lumbo-pelvic-hip complex in which exercise is inhibited (45)(46)(47). ...
... Overactive muscle strength or less active muscle strength, upper cross syndrome, and lower cross syndrome limitation within the whole body structure (47). The limitation is the forward head-rounded shoulder-and cervical kyphosis arising from the lumbo-pelvic-hip complex in which exercise is inhibited (45)(46)(47). Postural exercises prevent such syndromes as well as correct them. Separating, complex and comprehensive muscle activation corrective exercises (46). ...
Article
Full-text available
Postural musculature functioning emphasises the importance of dynamic actions in multiple motion stresses and the mechanical deficiencies of movement modelling. Human posture is a result of the distortion of space in different increments in static and dynamic conditions. Postural dysfunctions are caused by muscle tightness related to myofascicular stiffness. Herein, this traditional review explains the heat-and pain-induced syndromes, general mechanical deficiencies in muscle performance, and hypertrophy. Postural analysis shows the connection of motion system to biomechanics and kinesiology. Mechanical syndromes are caused by complex crossovers in the postural skeleton. Complex postural muscles confirm isometric modelling for limb fixation according to the location of compartment. However, different movement patterns in individualised exercises are inadequate and require further comparisons. Therefore, kinematic data regarding mechanical syndromes are limited. Moreover, this study shows how muscular performance should be involved in postural exercises. Postural muscle strength is the conditioning of the muscles in different working principles. Postural muscle dysfunctions should be analysed to compare atrophic characteristics. Current approaches present that postural analyses should be individualised to examine atrophic shortening and elongation because individuals have varied resistance and motion performance. This study aimed to explain development of mechanical syndromes to evaluate the indexes before postural exercises. These mechanical syndromes are presented in view of the longitudinal body kinesiology involved in comprehensive exercises.
... Eighteen studies targeted populations over 55-years of age or with a higher risk of osteoporosis (Benedetti et al., 2008;Bautmans et al., 2010;Bennell et al., 2010;Pfeifer et al., 2004Pfeifer et al., , 2011Hosseinabadi et al., 2020;Kaijser Alin et al., 2019;Bergstrom et al., 2011;Greendale et al., 2009;Itoi and Sinaki, 1994;Katzman et al., 2017aKatzman et al., , 2017bNaderi et al., 2019;Watson et al., 2019;Barker et al., 2020;Bulut et al., 2019;Gibbs et al., 2020;Cergel et al., 2019). Ten studies targeted younger age ranges (Toprak Celenay and Ozer Kaya, 2017;Balbas-Alvarez et al., 2018;Jaromi et al., 2012;Muyor et al., 2012;Seidi et al., 2014;Senthil et al., 2017;Çelenay ŞÖzer Kaya and Ö züdogru, 2015;Vaughn and Brown, 2007;Tarasi et al., 2019;Seidi et al., 2020). Thoracic kyphosis was measured using radiographic measurements in four studies (Itoi and Sinaki, 1994;Katzman et al., 2017aKatzman et al., , 2017bWatson et al., 2019). ...
... Thoracic kyphosis was measured using radiographic measurements in four studies (Itoi and Sinaki, 1994;Katzman et al., 2017aKatzman et al., , 2017bWatson et al., 2019). The remaining studies used external measures to measure the degree of kyphosis (Toprak Celenay and Ozer Kaya, 2017;Bautmans et al., 2010;Bennell et al., 2010;Pfeifer et al., 2011;Hosseinabadi et al., 2020;Bergstrom et al., 2011;Greendale et al., 2009;Katzman et al., 2017a;Katzman et al., 2017b;Naderi et al., 2019;Pfeifer et al., 2004;Watson et al., 2019;Barker et al., 2020;Bulut et al., 2019;Cergel et al., 2019;Jaromi et al., 2012;Muyor et al., 2012;Seidi et al., 2014;Çelenay ŞÖzer Kaya and Ö züdogru, 2015;Vaughn and Brown, 2007;Tarasi et al., 2019;Seidi et al., 2020), kyphotic index (Kaijser Alin et al., 2019;Watson et al., 2019;Balbas-Alvarez et al., 2018), posture number (Senthil et al., 2017), or amount of forward head posture (Benedetti et al., 2008;Gibbs et al., 2020). Only three studies performed follow-up measurements, at three-months (Seidi et al., 2020), six-months (Jaromi et al., 2012), or one-year (Barker et al., 2020;Jaromi et al., 2012). ...
... The remaining studies used external measures to measure the degree of kyphosis (Toprak Celenay and Ozer Kaya, 2017;Bautmans et al., 2010;Bennell et al., 2010;Pfeifer et al., 2011;Hosseinabadi et al., 2020;Bergstrom et al., 2011;Greendale et al., 2009;Katzman et al., 2017a;Katzman et al., 2017b;Naderi et al., 2019;Pfeifer et al., 2004;Watson et al., 2019;Barker et al., 2020;Bulut et al., 2019;Cergel et al., 2019;Jaromi et al., 2012;Muyor et al., 2012;Seidi et al., 2014;Çelenay ŞÖzer Kaya and Ö züdogru, 2015;Vaughn and Brown, 2007;Tarasi et al., 2019;Seidi et al., 2020), kyphotic index (Kaijser Alin et al., 2019;Watson et al., 2019;Balbas-Alvarez et al., 2018), posture number (Senthil et al., 2017), or amount of forward head posture (Benedetti et al., 2008;Gibbs et al., 2020). Only three studies performed follow-up measurements, at three-months (Seidi et al., 2020), six-months (Jaromi et al., 2012), or one-year (Barker et al., 2020;Jaromi et al., 2012). ...
Article
Background A variety of treatments aim to reduce thoracic hyperkyphosis in adults, thereby improving posture and reducing possible complications. Objective To investigate the effectiveness of treatments to reduce thoracic hyperkyphosis. Design Systematic review and meta-analysis. Methods MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to March 2021. Two authors independently selected randomised controlled trials assessing the effectiveness of treatments to reduce thoracic hyperkyphosis in adults. Raw data on mean change in thoracic kyphosis were extracted and standardised mean differences (SMD) calculated. Meta-analysis was performed on studies homogenous for study population and intervention. Strength of evidence was assessed using GRADE. Results Twenty-eight studies were included, with five meta-analyses performed. Low to moderate-quality evidence found structured exercise programs of three-months duration or less effective in reducing thoracic hyperkyphosis in younger (SMD -2.8; 95%CI -4.3 to -1.3) and older populations (SMD -0.3; 95%CI -0.6 to 0.0). Low-quality evidence found bracing for three months or more effective in older participants (SMD -1.0, 95%CI -1.3 to -0.7). A single study demonstrated the effectiveness of multimodal care in younger participants. The available evidence suggests multimodal care, structured exercise programs over three months duration, and taping in older adults, and biofeedback and muscle stimulation in younger adults, are ineffective in reducing thoracic hyperkyphosis. Conclusion Low to moderate-quality evidence indicates that structured exercise programs are effective to reduce thoracic hyperkyphosis. Low-quality evidence indicates that bracing is effective to reduce thoracic hyperkphosis in older adults.
... When the lower trapezius is neglected in strength training, as previously mentioned by weightlifters, or neglected naturally by the spinal flexion caused by prolonged electronic use, it theoretically results in biomechanical dysfunction that creates instability in the cervicothoracic region [4]. Therefore, consequently, maintaining this improper, rounded posture can lead to upper crossed syndrome, in which the lower trapezius, rhomboids, and serratus anterior are weakened, and the upper trapezius, pectoralis major and minor, and levator scapulae muscles are shortened [4,10]. These muscle imbalances results in pain. ...
... Under the overarching patient description of neck and shoulder pain, marked by underlying pathologies of upper crossed syndrome, scapulothoracic dyskinesia, and so on, the lower trapezius muscle undergoes potential changes as a result of these conditions. Despite this, there is still a limited amount of evidence on the clinical results from specific lower trapezius strength changes [10,14,[17][18][19][20]. This should be measured and utilized to activate the lower trapezius exercise in neck pain patients. ...
Article
Full-text available
Context Shoulder and neck pain are leading causes of disability worldwide. Rotator cuff pathology has strong associations with such pain and is extensively targeted by healthcare practitioners. A dysfunctional lower trapezius muscle has also been shown to contribute to neck and shoulder pain, yet it is often overlooked. Objectives This systematic review analyzes those with a history of, or who are currently managing, shoulder or neck pain to indicate differences in measures of lower trapezius function when compared to subjects without that pain. Methods Studies with no age restrictions were included in the study. Studies could determine lower trapezius muscle function with any quantifiable measurement tool or clinical assessment. If the study included a control group (no pain) and a comparator group (pain), and if lower trapezius muscle function was assessed in both, the study was typically included. The significance of the lower trapezius muscle function change was summarized in these pain patients. From a final total of 18 studies identified, level of muscle activity, muscle activation, time to onset, muscle strength, and muscle thickness were reported. Results The 18 included articles involved 485 participants with shoulder and/or neck pain and 455 without. Half of the shoulder pain studies (6/12), and all of the neck pain studies (6/6), demonstrated that the lower trapezius had a noticeable impact. The lower trapezius muscle in participants with shoulder and neck pain tended to show decreased muscle strength, and decreased time to onset/latency. Conclusions The findings from this systematic review should be taken into consideration when assessing and treating patients with shoulder and neck pain. Future studies that define the type and duration of shoulder and neck pain, as well as prospectively assessing lower trapezius muscle function in those with and without that pain, are needed.
... In this regard, some researchers have attempted to design appropriate exercise programs for reducing DKV, mainly formulated based on structural or functional approaches [12]. In the structural approach, changes in impaired movement patterns and malalignments are mainly attributed to peripheral factors assumed to lead to compensatory adjustments in the strength and length of involved muscles [13,14]. This approach focuses merely on strengthening weakened muscles while ignoring other related compensatory changes [13]. ...
... To the best of our knowledge, no study has ever dealt with DKV considering all three components of alignment, muscle activation, and movement patterns synchronously based on the comprehensive approach. Since DKV is a kind of sensorimotor dysfunction resulting in maladaptation in muscle activation and movement pattern, the CCEP can be applied to improve this condition as well [14,24]. ...
Article
Full-text available
Background Dynamic knee valgus (DKV) is a prevalent movement impairment widely regarded as a risk factor for lower extremity disorders such as patellofemoral pain syndrome. The present study aimed to investigate the effectiveness of the comprehensive corrective exercise program (CCEP) on kinematics and strength of lower extremities in males with DKV. Methods Thirty asymptomatic young men with DKV between the ages of 18 and 28 years participated in this study. They were randomly assigned to the intervention (n = 15) and control groups (n = 15). The intervention group performed the CCEP for three sessions per week for eight weeks, while the control group only did activities of daily living. Hip external rotator and abductor muscle strength and three-dimensional lower extremity kinematics consisting of knee varus/valgus, femur adduction/abduction, femur medial/lateral rotation, and tibial medial/lateral rotation were measured at the baseline and post-test. The data were analyzed using the analysis of covariance (ANCOVA). Results There were significant improvements in all kinematics variables in the intervention group after the 8-week CCEP. Moreover, the strength of abductor and external rotator muscle improved in the intervention group (P < 0.05). Conclusions The CCEP led to substantial improvements in the selected variables of lower extremity kinematics and muscle strength in participants with DKV during a single-leg squat. These results imply that practitioners should adopt a comprehensive approach to pay simultaneous attention to both proximal and distal segments for improving DKV. Trial registration The protocol has been approved in the Registry of Clinical Trials (Registration N: IRCT20180821040843N1) on 2018-12-30.
... In the process of voluntary movement of upper limbs, it is affected by the muscle force generated by the active contraction of skeletal muscles, the gravity of the limbs themselves, and the passive resistance generated by the viscoelasticity of soft tissues and the friction between tissues. In addition, when the speed and acceleration of movement are large, the influence of centrifugal force and inertial force should also be considered [6]. The gravity of the upper limb is related to its inertial parameters, but on the one hand, for specific subjects, the inertial parameters of the upper limb itself are not easy to obtain. ...
... where J + is the pseudoinverse of the nonsquare J T matrix. So far, the Jacobian matrix of the manipulator in the corresponding pose can be calculated from the joint angle, and the external moment of each joint space of the manipulator is mapped to the end generalized force acting on the center of the tool flange of the manipulator according to equation (6), and then, the auxiliary force and moment of the mechanical arm are obtained [17]. ...
Article
Full-text available
With the gradual expansion of the development of sports, the level of sports has been rapidly improved. Athletes have to carry out high-intensity and systemic technical movements in training and competition. Some sports have the greatest burden on the shoulder joint. From the observation and investigation of the injured parts of athletes, it is found that the shoulder joint is the most common sports injury, which is the most typical sports injury. Based on the problem of insufficient strength and endurance reserve after rehabilitation of shoulder external rotator injury, it will cause muscle tension and poor extensibility. To prove the improvement effect of functional training and posture index calibration on the poor posture of the shoulder, considering the measurement of global passive torque, this paper uses a limited set of joint angles and corresponding passive torque data in the upper arm lifting trajectory to train the neural network and uses the trained network to predict the passive torque in other upper arm trajectories. The kinematics model of the shoulder joint is established, and the human-computer interaction experiment is designed on the platform of the gesture index manipulator. The passive and active torque components of the shoulder joint in the human-computer interaction process are calculated by measuring the man-machine interaction force of the subjects in the motion state, which is used as the basis for evaluating the active motion intention of the subjects. Surface electromyography (SEMG) was used to calibrate and verify the attitude index of shoulder active torque. The method proposed in this paper is helpful to achieve more efficient on-demand assisted rehabilitation training exercises, which is of great significance to improve the level of rehabilitation training.
... While the assessment session did require a lot of talk and inquiry, sessions following the initial assessment were more actionbased, focusing not only on the traditional structural biomechanical approach to the upper crossed syndrome, including stretching of short muscles and strengthening of weakened muscles at the site of problem, but comprehensive corrective exercise program was administered. [13] [14] The selected exercises are designed in three phases: Initial, improvement, and maintenance where each exercise session begins with 10 min of warm-up activity and ends with 5 min of cool-down [ Figures 3 and 4]. ...
Article
Full-text available
Despite having a significant impact on the personal, psychological, and social dimensions of a person's health, health professionals' emphasis on the epidemiological, pathological, and physiological basis of the dysfunctional breathing, therefore, fails to provide patients with an appropriate treatment. Given the multifarious and psychophysiological nature of dysfunctional breathing, a holistic and multidimensional management would seem the most appropriate way to manage such a prevalent condition This case study presents a holistic approach to comprehensively manage dysfunctional breathing. That being the case, interventions for four key domains-biochemical aspects, biomechanical aspects, psychosocial aspects, and respiratory symptoms-were provided. It was obvious from the outcome findings that dysfunctional breathing can only be successfully understood by relating it to the person's life experiences including their, beliefs, values, emotions, influences, and social relations.
... The participants performed the following exercises: cross-body adduction, sleeper stretches, and corner stretches 2. Strength training: all participants performed 8 different strengthening exercises including ceiling punch, pron-T, and prone-Y, bilateral external rotation from zero degrees with Thera-Band, standing dynamic hug with Thera-Band, lawnmower, Blackburn, and Swedish swim (push up). The progression in intensity of exercises changed once every two sessions -changing the type of movement for both types of exercises, increasing the number of movements, sets for strength exercises, and increasing the time of stretch for stretching exercises -while observing the overload principle (Table 1) (3,14,20,30). First 3 10s Cross body adduction 3 10s Sleeper stretches Week 1 3 8 Ceiling punch 3 8 Pron T 3 10 Pron T 3 8 Prone Y 3 15s Cross body adduction 3 15s Sleeper stretches Week 2 3 8 Blackburn exercises 3 8 Bilateral external rotation 3 10 Bilateral external rotation 3 ...
Article
International Journal of Exercise Science 15(3): 962-973, 2022. Background: Stabilizing exercises reduce pain intensity, improves shoulder position and scapular function, and provides an appropriate strategy for the improvement of scapular dyskinesia. The purpose of this study was to investigate the effect of six weeks of stability exercises (stretching-strengthening) on joint proprioception, strength, and range of motion of the glenohumeral joint in female tennis players with scapular dyskinesia. Methods: Thirty-six female elite tennis players with scapular dyskinesia in both experimental and control groups participated in this study. Goniometer, Isokinetic and Biodex devices were used to evaluate the range of motion, internal and external rotation strength in 60° and 180°, and joint proprioception at 45° and 60°, respectively. Also, the lateral scapular slide test (LSST) was used to evaluate the scapulohumeral rhythm. For analyzing dependent variables and determining statistical significance the ANCOVA and an alpha of 5% was used. Results: The results of this study indicated the effect of the stability exercise program on the range of motion of internal (p = 0.016) and external (p = 0.023) rotation of the shoulder. Also, significant differences were observed between the control and training groups for internal rotation strength 60° (p = 0.013), 180° (p = 0.017) and external rotation strength 60° (p = 0.005), 180° (p = 0.045) and strength ratio 60° (p = 0.001) and 180° (p = 0.023). However, there were no significant differences for proprioception. Conclusion: In general, the findings of this study support the effectiveness of exercise therapy as a safe intervention for improving scapular function in tennis players with scapular dyskinesia.
... Inclusion criteria for the trial must comply with office workers between 30 and 45 years using a computer or lab-tops most commonly during the working day (about 30 h per week) with at least 5 years of experience [17,62]. Having alignment alteration includes forward head (≥ 45°), round shoulder (≥ 52°), and round back (≥ 42°) according to previous studies [63,64]. Marking pain intensity score visual analog scale (VAS) ≥3 in neck and shoulder [17,58,65]. ...
Article
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... contemporary neuroscience and motor control theories [45] argue that pain alters motor pattern/control in different ways in response to the individual's conscious and unconscious perception of threat, and this can generate changes in motor function and movement. Moreover, characteristics of muscle synergies can change in the presence of pain [46] and they are associated with biomechanical, motor control, and performance variables [47]. ...
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