The aim of this study is to investigate the effects of exercises applied using the Proprioceptive Neuromuscular Facilitation (PNF) technique on pain, joint range of motion, muscle strength, and posture in individuals with Upper Crossed Syndrome, and to compare these effects with patient education. Individuals diagnosed with Upper Crossed Syndrome will be included in the study and allocated into two groups: a PNF-based exercise combined with patient education group and a patient education-only group. In the PNF group, Stabilizing Reversals for scapular anterior elevation-posterior depression and Replication techniques for posterior depression will be applied. In the patient education group, education including postural awareness and exercise will be provided. Assessments will be conducted at two time points, before and after the intervention. Pain level, joint range of motion, muscle strength and endurance, and postural parameters will be analyzed. This study is expected to provide evidence regarding the clinical effectiveness of PNF approaches targeting scapular control in individuals with Upper Crossed Syndrome and to contribute to the management of postural disorders in the field of physiotherapy and rehabilitation.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
TRIPLE
Enrollment
38
Participants in the patient education group will receive a single face-to-face patient education session at the beginning of the study. This education will include information on postural awareness, correct sitting posture, and maintaining proper posture during activities of daily living. In addition, participants will be provided with a prepared educational brochure and will be asked to perform the two postural exercises included in the brochure three days per week for a total duration of four weeks. Participants will be encouraged to integrate the postural principles taught during the education into their daily lives.
In the PNF, trunk correction in the sitting position, approximation, and the application of Stabilizing Reversals in the direction of scapular posterior depression-anterior elevation and Replication techniques toward scapular posterior depression in the side-lying position will be performed. These interventions are planned to be applied three days per week, with a total intervention duration of four weeks.
Istanbul Atlas University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation
Istanbul, Istanbul, Turkey (Türkiye)
Posture Assesment
Posture will be assessed using the Posture Screen Mobile (PSM) application (Backbone Software, Inc., USA), a valid and reliable mobile application designed for postural analysis. Participants will be positioned in a static standing posture on a flat surface, with their feet parallel, wearing appropriate clothing that allows visualization of the upper body and lower extremities. Photographs will be taken from the anterior, posterior, and lateral views using a mobile device placed at a standardized distance. During the assessment, the application will automatically identify anatomical reference points (e.g., ears, shoulders, pelvis). Based on these reference points, postural deviations will be calculated and reported by the software. Anterior and posterior postural deviations in the frontal plane and lateral postural deviations in the sagittal plane will be recorded for each participant.
Time frame: Baseline and up to 8 weeks
Muscle Strength Assessment
Muscle strength of the thoracic back extensor muscles and abdominal muscles (upper, lower, and oblique abdominal muscles) will be assessed before and after the intervention using manual muscle testing performed by the same physiotherapist (Scoring 0-5). Upper abdominal muscle strength will be evaluated in the supine position using graded trunk flexion tasks with varying arm positions as resistance. Lower abdominal muscle strength will be assessed in the supine position by recording the ability to maintain lumbopelvic stability while the lower extremities are slowly lowered from 90° hip flexion. Oblique abdominal muscle strength will be evaluated through trunk flexion combined with rotation, with scoring based on movement quality and scapular clearance criteria.
Time frame: Baseline and up to 8 weeks
Pain Assessment
The level of back pain will be assessed using the Visual Analog Scale (VAS). The VAS consists of a 10-cm horizontal line, with the endpoints labeled "no pain" and "unbearable pain." Participants will be asked to mark the point on the scale that best represents the intensity of their pain. Pain intensity will be determined by measuring the distance in centimeters from the "no pain" anchor to the participant's mark.
Time frame: Baseline and up to 8 weeks
Muscle Endurance
Muscle endurance of the thoracic and lumbar back extensor muscles and the abdominal muscles (upper, lower, and oblique abdominal muscles) will be assessed. Endurance of the thoracic and lumbar back extensors will be evaluated using the Biering-Sorensen Test, a valid and reliable method for assessing isometric endurance of spinal extensor muscles. The duration for which the test position can be maintained will be recorded in seconds. Abdominal muscle endurance will be assessed by recording the holding time (in seconds) at the final position of the highest achievable manual muscle test score. Upper abdominal muscle endurance will be evaluated using the Bench Trunk Curl Test, oblique abdominal muscle endurance will be measured using the Flexion-Rotation Trunk Endurance Test, and lower abdominal muscle endurance will be assessed by recording the duration for which an isometric position requiring lumbopelvic stability can be maintained.
Time frame: Baseline and up to 8 weeks
Muscle Length Tests
Muscle length tests will be performed for the following muscle groups. Pectoralis Major (sternal and clavicular portions): Muscle length will be assessed in the supine position by measuring the distance between the lateral epicondyle of the humerus and the examination table on both sides. The upper limb will be positioned in shoulder external rotation with standardized abduction angles (135° for the sternal portion and 90° for the clavicular portion) and elbow extension. The measured distance will be recorded as an indicator of muscle tightness. Pectoralis Minor: Muscle length will be evaluated in the supine position by measuring the distance between the acromion and the examination table bilaterally. Greater distances will indicate increased muscle tightness. Hamstring Muscles: Hamstring muscle length will be assessed bilaterally using the straight leg raise test in the supine position. Hip flexion range of motion will be measured with a universal goniometer and recorded in degree
Time frame: Baseline and up to 8 weeks
Range of Motion Assessment
Trunk range of motion, including flexion, extension, lateral flexion, and rotation, will be assessed using a goniometric method. Measurements will be recorded in degrees using Saehan steel goniometers. Trunk flexion and extension will be measured in the standing position, with the goniometer aligned to anatomical landmarks of the lumbosacral region. Trunk lateral flexion will be assessed in standing, with the goniometer positioned to follow the spinal alignment. Trunk rotation will also be measured in the standing position, and the angle achieved during rotation will be recorded in degrees.
Time frame: Baseline and up to 8 weeks
Flexibility Tests
Trunk flexion flexibility will be assessed using the sit-and-reach test. Participants will be seated on a firm surface with the knees extended and instructed to reach forward toward their feet without bending the knees. The distance reached will be measured in centimeters using a measuring tape. Trunk extension, lateral flexion, and rotation flexibility will be assessed in the standing position. The distances achieved in the respective movement directions will be measured in centimeters using a measuring tape and recorded.
Time frame: Baseline and up to 8 weeks
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