The Effect of Neuromuscular Combined with Biomechanical Scapular Stabilizer Muscle Corrective Exercises on Upper Crossed Syndrome in Chinese Secondary School Students: A Randomized Controlled Trial

The Effect of Neuromuscular Combined with Biomechanical Scapular Stabilizer Muscle Corrective Exercises on Upper Crossed Syndrome in Chinese Secondary School Students: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Neuromuscular Combined with Biomechanical Scapular Stabilizer Muscle Corrective Exercises on Upper Crossed Syndrome in Chinese Secondary School Students: A Randomized Controlled Trial Xuanming Hu, Guiying Bao, Xi Quan, Kai Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5789540/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Objectives Upper crossed syndrome (UCS), characterized by poor posture, neck pain and Functional disability, is a prevalent issue among youth. This study aims to evaluate the effects of neuromuscular combined with biomechanical exercise (NCBE) on UCS among secondary school students and compares its outcomes with biomechanical exercise (BE) alone. Methods Forty-five male secondary school students (aged 15–18) were divided into three groups: NCBE (n=15), BE (n=15), and a control group (n=15). The NCBE group underwent combined neuromuscular and biomechanical exercise, the BE group performed biomechanical exercise only, and the control group participated in regular physical activities. Interventions were conducted three times a week for eight weeks. Outcome measures, including Forward Head Angle (FHA), Rounded Shoulder Distance (RSD), Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and scapular muscle strength (Middle Trapezius (MT), Lower Trapezius (LT), Serratus Anterior (SA) ), were assessed at baseline, week 4, and week 8. Results Within-group comparisons: Both BE and NCBE groups showed significant improvements in all measures by week 4 compared to baseline (p<0.05), with further improvements by week 8 (p0.05). Between the group comparisons: Both BE and NCBE groups had better outcomes than the control group at weeks 4 and 8 (p<0.05). NCBE group showed superior results compared to the BE group only in the strength of MT, LT and SA (p<0.05) in week 4. NCBE group showed superior results compared to BE in FHA, NDI, VAS and the strength of MT, LT and SA (p0.05) at week 8. Conclusion Both NCBE and BE are effective in alleviating UCS symptoms in Chinese secondary school students. However, NCBE demonstrates superior treatment effects compared to BE across multiple outcome measures, offering a promising and cost-effective therapeutic option. Additionally, regular physical activity is ineffective in treating UCS. Upper crossed syndrome Forward head posture Round shoulder Scapular stabilizer muscle corrective exercises Secondary school students Figures Figure 1 Figure 2 1 Introduction In 1979, neurologist Dr. Vladimir Janda first introduced the concept of Upper Crossed Syndrome (UCS), a muscular imbalance pattern involving the head and shoulder regions. UCS is commonly observed among individuals who spend prolonged periods sitting or working at a desk and have poor posture throughout the day [ 1 ]. This muscular imbalance manifests as tightness and shortening of the upper trapezius, pectoralis major, and pectoralis minor muscles. In contrast, the rhomboids, middle and lower trapezius, and serratus anterior muscles are passively stretched and weakened. These imbalances contribute to UCS-related symptoms [ 2 , 3 ]. Prolonged sitting with poor posture is a significant contributing factor to UCS. Research indicates that as total sitting time increases, the degree of postural abnormality also rises, with each additional unit of weekly sitting time leading to a 75.1% increase in postural dysfunction scores [ 4 ]. Extended sitting causes fatigue in the lumbar extensors, making it difficult to maintain the natural spinal curvature. This poor posture may lead to underactivation of specific muscles and overactivation of others [ 5 ], ultimately resulting in habitual forward head posture, rounded shoulders, and thoracic kyphosis [ 6 ]. Due to academic pressures and prolonged use of electronic devices, sedentary behavior and screen time among Chinese adolescents have significantly increased in recent years. Studies show that Chinese adolescents spend an average of nearly 8 hours per daily sitting [ 7 ], with screen time averaging 1.04 ± 1.50 hours on school days and 2.56 ± 2.45 hours on weekends, which exceeds the World Health Organization (WHO) recommended 2-hour limit [ 8 ]. In China, secondary school students are a high-risk group for UCS. A 2019 study in Shanghai found that rounded shoulders and forward head posture were the most common postural abnormalities in secondary school students, with prevalence rates of 60.5% and 58.1%, respectively [ 9 ]. A 2020 study on middle school students in Nanjing reported that the most prominent postural issues were forward head posture and rounded shoulders, affecting 68% and 52% of students, respectively [ 10 ]. A 2022 posture screening in Beijing’s Xicheng District showed that 99.34% of first-year high school students exhibited forward head posture, and 60.9% had abnormal thoracic kyphosis [ 11 ]. The misalignment associated with UCS causes various problems for students: (1) Chronic neck and shoulder pain, often resulting in cervical spine disorders [ 12 ]; (2) Functional abnormalities in the neck and shoulder region, such as narrowing of the subacromial joint capsule, which leads to shoulder impingement syndrome and disrupts daily activities [ 13 ]; (3) Psychological issues, including lowered self-esteem and body image concerns due to altered posture [ 14 ]; (4) Altered shoulder joint mechanics, placing excessive strain on the cervical-thoracic junction, C4-5 and T4 segments, and the shoulder, potentially causing angina and chest pain [ 15 ], and negatively impacting respiratory efficiency and lung capacity [ 12 ]. Secondary school students are in a critical period of growth and development, during which their muscles and bones show significant plasticity. Their alignment is not only highly susceptible to the effects of poor habits but also responsive to appropriate interventions. However, due to academic pressures and limited time and energy, traditional, time-consuming treatments are often impractical for this group. To effectively address UCS in secondary school students, several key factors must be considered: First, given the widespread nature of posture problems among adolescents, interventions should be low-cost, portable, and applicable to a broad population; Second, as secondary school students are in a sensitive developmental phase, treatments must ensure safety and avoid any adverse effects on normal growth; Third, due to academic burdens, treatment plans should be simplified to minimize disruption to students’ daily studies while ensuring efficacy; Fourth, poor posture in school students primarily results from altered muscle function [ 16 ]. Scapular stabilizer corrective exercise aims to enhance muscular function while adhering to the physiological load-bearing capacity of students. This approach is more effective than other methods, such as physical therapy, in improving posture, increasing joint mobility, and enhancing muscle flexibility, making it the preferred intervention [ 17 ]. Currently, scapular stabilizer corrective exercises are generally based on two distinct theories: biomechanical factors and neuromuscular factors. From a biomechanical perspective, abnormal alignments in UCS are attributed to imbalances in muscle length and strength [ 18 ]. Exercises within this paradigm focus on restoring muscle balance by rehabilitating muscle length and strength to treat UCS. Conversely, from a neuromuscular standpoint, abnormal joint alignments in UCS are considered to stem from abnormalities in the nerves’ control of muscles [ 19 ]. This approach emphasizes increasing exercise recruitment, establishing good movement patterns, and gradually forming exercise habits to restore normal joint positions [ 20 ]. However, traditional therapeutic approaches predominantly attribute functional abnormalities of UCS to biomechanical factors [ 20 ], potentially overlooking other contributory factors such as those related to neuromuscular aspects [ 21 ]. Neglecting neuromuscular factors may result in limited therapeutic efficacy, and studies have indicated that isolated biomechanical exercises may not effectively improve abnormal alignment [ 22 ]. Therefore, an integrative exercise strategy that combines biomechanical and neuromuscular approaches appears critical. This comprehensive method aims to optimize the function of scapular stabilizers from multiple dimensions, providing patients with a more thorough and effective therapeutic solution. A randomized controlled trial (RCT) was conducted to address this gap. The primary objective was to evaluate neuromuscular effects combined with biomechanical exercise (NCBE) on UCS in secondary school students. The secondary objective was to compare NCBE with biomechanical exercise (BE) alone and to analyze the potential mechanisms underlying the treatment effects. Hypothesis 1 Both the NCBE and BE will be effective in treating UCS in secondary school students. Hypothesis 2 The NCBE will be more effective in treating UCS in secondary school students compared to BE. 2 Methods 2.1 Study Design This study employed a randomized controlled trial (RCT) design to evaluate and compare the effects of neuromuscular combined with biomechanical scapular stabilizer exercises (NCBE) and purely biomechanical scapular stabilizer exercises (BE) on UCS in secondary school students. The study was conducted over 14 weeks, from July 10, 2024, to October 13, 2024, at a secondary school in Tongliao, China. 2.2 Participants and Eligibility Criteria The sample size was determined using G*Power 3.1.9.2 software. Based on previous studies, the effect size was estimated to be 0.66 [ 23 ]. We aimed to achieve 80% statistical power at a two-tailed significance level (α = 0.05). The sample size calculation indicated that at least 39 participants were required to achieve the desired power. The target sample size was increased to 45 participants to account for potential dropout. These participants were randomly assigned to three groups, with 15 participants per group. Inclusion Criteria Secondary school students aged 15–18 years, with a forward head posture angle greater than 45° [ 24 , 25 ], a rounded shoulder distance greater than 5.6 cm [ 26 ], mild to moderate pain (VAS score 10–60 mm) [ 27 ], and willingness to participate in the trial. Exclusion Criteria Participants with a history of disease, fractures, surgeries, joint issues, spinal injuries, abnormal BMI, diagnosed muscular pathology, cervical soft tissue fractures, or those unable to attend at least three exercise sessions per week. A total of 45 male secondary school students aged 15–18 years who met the inclusion and exclusion criteria for UCS were recruited from the secondary school. All participants were informed of the study’s purpose, procedures, and potential risks before participation. Written informed consent was obtained from both the participants and their parents. Participants were informed of their right to withdraw from the study at any time without facing any adverse consequences. The study design was approved by the Ethics Committee of Nanjing Sport Institute(Approval No: [RT-2024-13]), and it adhered to the ethical principles outlined in the Declaration of Helsinki (2013). 2.3 Randomization Prior to randomization, all potential participants underwent eligibility assessments. A computer-generated randomization list was used, employing block randomization to ensure participants were allocated in a 1:1:1 ratio to the neuromuscular combined with the biomechanical exercise group (NCBE group), the biomechanical exercise group (BE group), and the control group. The block size was kept confidential to prevent the prediction of group allocation. An independent statistician was responsible for the randomization process and was kept blinded by the trial personnel to ensure that group assignments were concealed. Statisticians recorded the group assignments for each participant, stored them in a secure database, and verified the randomization results for each stratification combination. To prevent selection bias, allocation concealment was implemented. Specifically, the generated random sequence was sealed in opaque envelopes; each labelled only with the participant’s ID. After completing baseline assessments, the researchers opened the envelopes sequentially according to participant IDs to determine their group allocation. Subsequently, the 45 participants were randomly assigned to one of the three groups: the control group, the BE group, or the NCBE group, with 15 participants in each group. Baseline data were collected for all participants, including age, height, weight, and UCS-related measurements (including forward head angle (FHA), rounded shoulder distance (RSD), neck disability index (NDI), visual analog scale (VAS) score, and strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) ). An analysis of variance (ANOVA) was conducted to compare baseline data among the groups to ensure no significant differences in baseline characteristics. Adjustments were made using covariates or other statistical methods if significant differences were detected. The final statistical analysis showed no significant differences across groups regarding age, height, weight and UCS-related measurements (p > 0.05), indicating successful baseline equivalence. We adhered to the CONSORT guidelines and created a flowchart (see Fig. 1 ) detailing the entire process, from eligibility screening, enrollment, randomization, intervention, and outcome measurements. 2.4 Intervention Restoring the degree of muscle activation is crucial in neuromuscular interventions [ 19 ]. Biomechanical interventions focus on restoring the muscle length of overactive muscles and strengthening weak muscles [ 28 ]. Current neuromuscular treatments include electromyographic biofeedback training, muscle energy techniques (MET), proprioceptive neuromuscular facilitation (PNF) training, scapular motor control exercises, and postural correction exercises. Biomechanical interventions primarily involve myofascial release, stretching, and strength exercise. In neuromuscular exercises, Mottram et al. [ 29 ] implemented Scapular-Oriented Exercises (SOE) and found that SOE significantly improved scapular positioning and activation of the scapular muscles. Wegner et al. [ 30 ] conducted postural correction exercises for patients with neck pain, effectively adjusting the activity pattern of the trapezius muscles and bringing them closer to the performance of healthy individuals. Cools et al. [ 31 ] combined postural correction exercises with scapular movement control, encouraging participants to frequently practice correct postural habits in daily life, thereby fostering long-term behavioral change [ 32 ]. Seidi et al. [ 24 ] emphasized the importance of considering neuromuscular factors when treating UCS, stressing the need to focus not only on external factors, such as chest elevation, shoulder depression, and chin retraction but also on internal factors, specifically the precise control of scapular positioning by the scapular muscles. In biomechanical exercises, Sasun et al. [ 33 ] demonstrated that myofascial rolling exercises were more effective than isometric relaxation techniques in alleviating pain and improving posture in UCS patients. Shadi et al. [ 34 ], based on the National Academy of Sports Medicine (NASM) principles, developed a corrective exercise program that included stretching and strength exercises. After 6 weeks of intervention, this program showed superior results compared to Pilates or the Alexander Technique, particularly in correcting UCS-related abnormal alignments. The NASM Corrective Exercise Specialist (CES) certification program emphasizes assessing and managing movement dysfunctions, muscle imbalances, and posture-related issues [ 35 ]. Existing evidence supports the significant efficacy of NASM-based corrective exercises in treating UCS [ 36 ]. Based on the above research findings, this study aims to develop a modified exercise program that combines neuromuscular and biomechanical approaches, utilizing portable and easily applicable student exercises. The neuromuscular component focuses on postural corrective exercises and scapular motor control exercises. In contrast, the biomechanical component follows NASM guidelines and focuses on enhancing the function of the scapular stabilizer muscles, which includes content such as myofascial release, stretching exercises, and strength exercises. The specific components of the exercise program are outlined as follows: Postural Correction Exercises: Re-educating the neutral spinal position and correcting cervical, thoracic, and lumbar postures to help patients establish correct postural habits [ 31 ]. Scapular Motor Control Exercises: Proprioceptive training for the scapular muscles aimed at improving neuromuscular control, retraining muscle recruitment patterns, and enhancing scapular movement patterns [ 30 ]. Myofascial Release: Myofascial pain is a condition caused by trigger points (TrP) within muscles or fascia. Trigger points are characterized by localized tenderness and excessive stimulation. Myofascial release involves gradually applying pressure to active trigger points (MTrP) until the patient feels a release of pressure, which helps elongate muscle fibers and increase the range of motion while reducing muscle tension [ 37 ]. Stretching Exercises: Static stretching involves slowly stretching the muscle to a specified position and holding it for some time. This technique can help alleviate pain, disability, and increase range of motion (ROM), especially for patients with cervical disc disease or non-specific pain [ 38 ]. Strength Exercises: Using external resistance (resistance bands) to enhance the strength and endurance of the scapular muscles, thus improving joint stability. To ensure the objectivity of the exercise program design, we interviewed five experts, including two sports medicine specialists and three kinesiology experts, who evaluated the selected exercises for treating UCS in secondary school students. Based on their feedback, we confirmed the feasibility of implementing the program. 2.4.1 Neuromuscular Exercises Postural Correction Exercises Followed by Scapular Motor Control Exercises. Postural Correction Exercises : Principle: During the first 4 weeks, the therapist assists the participants in correcting their posture; after the 4th week, participants are encouraged to correct their posture independently, with the therapist observing and supervising. The intervention is divided into two steps: Step 1 Achieving neutral lumbar spine and pelvis position through tactile feedback and verbal cues. Step 2 Using verbal prompts such as “chest up, shoulders down, chin in” to help participants adjust their thoracic and cervical postures. Scapular Motor Control Exercises : Principle: During the first 4 weeks, the therapist assists the participants in improving scapular movement control; after the 4th week, participants are encouraged to independently control scapular movement, with the therapist observing and supervising. The intervention is divided into three steps: Step 1 Explain and demonstrate the scapula’s optimal resting position and movement patterns using verbal instructions and video presentations, ensuring students internalize the correct scapular positioning. Step 2 : The therapist uses manual contact and verbal cues to guide participants in consciously positioning the scapula in the optimal location [ 39 ]. The following guidelines are followed: Visual cues: The scapula should be positioned between the second and seventh ribs in the posterior thoracic region [ 40 ]. Tactile cues: The relative position of the scapula can be assessed through palpation of the spine and scapula. The optimal position is when the superior angle of the scapula is aligned with the spinous process of T2 or T3, the root of the scapular spine aligns with the spinous process of T3 or T4, and the inferior angle aligns with T7, T8, or T9. However, it may descend as low as T10 [ 41 ]. It is important to note that the scapula is not positioned on the frontal plane of the thorax but is instead positioned at a 30-degree angle relative to the thorax [ 42 ]. Step 3 : Scapular Orientation Exercises: The therapist uses manual contact and verbal cues to guide participants in performing scapular movements autonomously, including protraction, retraction, elevation, depression, upward rotation, downward rotation, internal rotation, and external rotation, to facilitate proper scapular motion [ 29 , 43 ]. 2.4.2 Biomechanical Exercises The sequence of exercises is as follows: fascia release, stretching exercises, and strengthening exercises. Fascia Release (Progressive Pressure Release) Principle: Slowly roll the fascia ball over the target muscle groups, focusing on areas of muscle soreness and trigger points. The ball may be held still or rolled repeatedly over the painful areas until tension and pain are alleviated. In the first four weeks, each exercise is repeated 3 times, with each repetition lasting 90 seconds. After the fourth week, gradually increase the pressure applied to the muscle fascia, ensuring the resistance is not excessive. Each exercise is repeated 4 times, with each repetition lasting 120 seconds. After 90–120 seconds of fascia release, the tissue undergoes histological changes, and after several releases, the tissue becomes softer and more flexible [ 44 ]. 1. Fascia Release for the Neck Extensor Muscles Stand with your back against the wall and place the fascia ball on the posterior neck muscles. Use body weight to gradually increase the ball’s pressure on the muscle, rolling and pressing along the direction of the upper trapezius and levator scapula muscles. 2. Fascia Release for the Chest Muscles : Stand facing the wall and place the fascia ball on the chest. Ensure the ball is in direct contact with the pectoral muscles, using body weight to apply pressure to the muscles gradually. Roll and press along the fiber direction of the pectoralis major and minor. Stretching Exercises Principle: Stretching should be slow and smooth, avoiding rapid or forceful movements to prevent muscle strain. Gradually increase the stretch range until a mild stretch is felt, but not pain. In the first 4 weeks, each exercise is repeated 3 times, holding each stretch for 20 seconds. After the fourth week, each exercise is repeated 4 times, holding each stretch for 20 seconds. The following presentation of stretching exercises focuses on the right side of the body. 1. Stretching the Pectoralis Major and Minor : Place the right hand or forearm on a door frame, with the elbow slightly higher than the shoulder height. Step forward with one foot and push the body forward to stretch the chest muscles. Stretching the Upper Trapezius and Levator Scapulae : Grasp the head with the left hand and hold a fixed object with the right hand. Gently pull the head downward to the left side while slightly rotating the head to the right. Strengthening Exercises Principle: Ensure that the target muscle groups are fully engaged during each movement to avoid compensation by other muscles. In the first 4 weeks: Perform three sets of each exercise, with 8–10 repetitions per set. After the fourth week: Gradually increase resistance based on individual strength levels. Perform four sets of each exercise, with 12–15 repetitions per set. (1) Bent-Over Y-Raise Starting Position: Stand with your body bent forward at a 30° to 45° angle to the floor, keeping your back straight. Flex both arms forward at a 90° angle, positioned in front of your chest. Movement: Use the scapular muscles to flex both arms to 180°, forming a “Y” shape with your torso and thumbs pointing toward the ceiling. (2) Bent-Over W-Exercise Starting Position: Stand with your body bent forward at a 30° to 45° angle to the floor, keeping your back straight. Flex your upper arms with your elbows at a 90° angle, positioning your forearms parallel to your chest in front of your body. Movement: Initiate the movement by retracting the scapula, pulling them inward, which will bring your arms and torso into a “W” shape. During the movement, focus on the contraction of the upper back muscles and the tension as the scapula comes closer together. (3) Resistance Band T-Extension Starting position: Stand with the torso in a neutral position. Arm flex to 90°, positioned in front of the chest. Movement: Maintain the arms at 90° of shoulder flexion and move the shoulder joint into abduction in the horizontal plane. (4) Resistance Band External Rotation Exercise Starting position: Stand with feet shoulder-width apart, holding the resistance band with both hands. Elbows were bent at 90°, with the upper arms close to the body and forearms parallel to the ground. Movement: Contract the shoulder muscles to externally rotate the forearms, ensuring the upper arm is close to the torso throughout the movement. (5) Foam Roller Wall Slide Starting Position: Stand facing a wall, with forearms at shoulder width apart and the foam roller at eye level. Flex the elbows and press the foam roller against the wall. Movement: Exhale and press the foam roller upward, bringing the arms overhead while feeling the serratus anterior contract to rotate the scapulae upwardly. Inhale as you press the foam roller downward, feeling the downward rotation of the scapulae. Repeat for four sets of 20 repetitions, ensuring not to shrug the shoulders during the upward movement. (6) Wide-Grip Resistance Band Row Starting position: Stand with feet shoulder-width apart, holding the resistance band with both hands, hands positioned wider than shoulder-width. Both arms flexed to a certain angle with elbows extended and core engaged. Movement: Retract the scapula towards the spine, bending the elbows and pulling the resistance band towards the sides of the shoulders. During the pull, avoid over-relying on the arms and focus on activating the upper back muscles (such as the middle trapezius and rhomboids) for the movement. (7) Deep Cervical Flexor Exercise Students were instructed to stand or sit with the torso in a neutral position, gently tucking the chin toward the neck. Ensure that the “occiput-neck-back” forms a straight line. Attach the middle of the resistance band to the back of the head. Movement: then they grasp the ends of the resistance band with both hands and pull forward, resisting the band’s pull as the head extends backwards against the resistance. This isometric contraction maintains a straight line with the head, neck, and back. In the first 4 weeks, they were instructed to repeat three sets, each lasting 30 seconds. After the fourth week, repeat four sets, each lasting 1 minute. Note (1) Two qualified rehabilitation coaches trained the BE and NCBE groups. Both coaches received training for this experiment before the trial and were proficient in the required corrective exercise techniques. During the training, a therapist with over 10 years of experience in physical therapy supervised and guided the participants. (2) In the first week before the experiment officially began, participants in both the NCBE and BE groups were taught the principles and the correct execution of the exercises. (3) Corrective exercises for the BE and NCBE groups were conducted in an open training environment, with sessions occurring three times per week for a total of 8 weeks. After the fourth week of exercise intervention, participants who could complete the exercises without difficulty or whose symptoms did not worsen progressed to the next level of exercise. If participants experienced pain or physical discomfort during the experiment, they would stop the training or withdraw from the study. (4) For the NCBE group, the neuromuscular corrective exercises were performed first, followed by the biomechanical corrective exercises. 2.5 Outcome Measures On weeks 4 and 8 (post-intervention), measurements were taken before the intervention. Three physical therapists, each trained in the trial protocol, performed the measurements for all three groups. The measurements were supervised by a therapist with over 10 years of experience in physical therapy. The three physical therapists independently assessed the control, BE, and NCBE groups while remaining blinded to the group assignments. The outcome measures included a comprehensive assessment of the participants’ age, height, and weight, as well as evaluations of forward head posture, rounded shoulder posture, neck disability, neck pain, and isometric strength of the scapular muscles(middle trapezius, lower trapezius, serratus anterior). The specific methods for measuring each outcome are as follows: 2.5.1 Measurement of Forward Head Posture The photographic measurement method was used, with the digital camera placed 265 cm away from the wall and its height adjusted to the level of the participant’s right shoulder. The participant was asked to perform three forward bends and three overhead arm raises in this position and then return to a comfortable and natural standing position. Three photos were taken from the participant’s right side [ 46 ], and these images were imported into AutoCAD to measure the forward head angle (FHA) [ 25 , 47 ]. The angle between the line from the ear tragus to C7 and the vertical line was measured (see Fig. 2 ), and an angle greater than 45° was considered abnormal [ 24 , 25 ]. The average of these three photos was recorded. Ruivo et al. reported the intra- and inter-rater reliability of photographic measurements of forward head posture as ICC = 0.87 and 0.66, respectively [ 48 ]. 2.5.2 Measurement of Round Shoulder Round shoulder refers to the forward displacement of the acromion relative to the spinous process of the seventh cervical vertebra. In this study, the degree of the round shoulder is quantified by the round shoulder distance (RSD). One end of the caliper is placed at the anterior acromion point. In contrast, the other end is positioned at the same coronal plane as the C7 vertebra and at the same sagittal plane as the anterior acromion. A built-in spirit level confirms that the caliper is perfectly horizontal, i.e., parallel to the ground. Once the caliper is correctly aligned, the straight-line distance between the two ends is recorded as the measurement result. The reliability of this measurement technique, with an ICC value of 0.91, is clinically significant [ 26 ]. 2.5.3 Measurement of Neck Disability Neck disability was measured using the neck disability index (NDI), a valid and reliable questionnaire comprising 10 items related to pain intensity, personal care, lifting, reading, concentrating, work, driving, sleeping, recreation, and headaches. Each question has six possible answers, with scores ranging from 0 (no pain or functional limitation) to 5 (severe pain and maximum limitation). Patients were required to select the response that most accurately reflects their current condition. The calculation method is as follows: Total score = \(\:\frac{\text{S}\text{u}\text{m}\:\text{o}\text{f}\:\text{s}\text{c}\text{o}\text{r}\text{e}\text{s}\:\text{f}\text{o}\text{r}\:\text{a}\text{l}\text{l}\:\text{i}\text{t}\text{e}\text{m}\text{s}}{\text{N}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{c}\text{o}\text{m}\text{p}\text{l}\text{e}\text{t}\text{e}\text{d}\:\text{i}\text{t}\text{e}\text{m}\text{s}\times\:5}\times\:100\text{ %}\) The scores are presented as a percentage, with higher scores indicating greater disability. The interpretation of scores is as follows: 0–20% indicates mild disability, 21%-40% indicates moderate disability, 41%-60% indicates severe disability, 61%-80% indicates very severe disability, and 81%-100% indicates complete disability [ 49 ]. This study used the Simplified Chinese version of the NDI, which has demonstrated excellent internal consistency (Cronbach’s α = 0.92) and good test-retest reliability (ICC2,1 = 0.85) [ 50 ]. 2.5.4 Measurement of Neck Pain Intensity A 100-mm visual analog scale (VAS) was used to assess the intensity of neck pain in participants. The scale is anchored by “0” representing “no pain” and “100” representing “the most severe pain.” Participants were instructed to mark the point on the 100-mm line representing the most severe pain they experienced in the past 24 hours. The distance from the left end of the scale to the marked point was then measured and recorded in millimeters [ 51 , 52 ]. 2.5.5 Measurement of Strength of Scapular Muscles Manual muscle testing (MMT) was used to measure the strength of scapular muscles, utilizing a handheld dynamometer (HHD). The HHD used in this study was the Hoggan MicroFET2™, a tool for quantifying muscle strength. During scapular muscle testing, the HHD provides reliable isometric muscle force measurements for the middle trapezius, lower trapezius, and serratus anterior muscles. The inter-rater reliability coefficient for the measurements ranged from 0.89 to 0.96, indicating excellent reliability [ 53 ]. The principle of MMT involves applying resistance in the opposite direction of the muscle contraction [ 53 ]. During the measurement, the primary target muscle should exhibit the highest activity level compared to secondary or stabilizing muscles. The HHD was positioned at the midpoint of the specific muscle being tested. Resistance was gradually applied through the HHD until the force exerted by the examiner was equal to the force exerted by the participant, achieving maximal isometric contraction. The strength of the target muscle during maximal isometric contraction was measured [ 53 ]. If force balance was not achieved between the examiner and participant, or if the participant experienced pain, the test was stopped, and a brief rest period was taken before resuming. A 2-minute rest was allowed between each muscle strength test. The strength test for the dominant muscle was repeated three times, and the average of the three maximal strength values was used for data analysis, with measurements recorded in kilograms [ 54 ]. The students in the control and BE groups and three different examiners tested the NCBE group. These three examiners received training on the muscle testing procedures for this study prior to the tests, which a therapist supervised with approximately 10 years of experience in physical therapy. Middle Trapezius Scapular retraction is the movement of the scapula during MT contraction. According to Hislop et al., the resistance from the HHD is applied to the scapular spine, located midway between the acromion and the root of the scapular spine. The force is applied transversely and parallel to the long axis of the humerus, with the humerus abducted at 90 degrees [ 55 ]. Lower Trapezius Scapular retraction and depression are the movements of the scapula during LT contraction. Following Hislop et al.’s description, the resistance from the HHD is applied to the scapular spine at the midpoint between the acromion and the root of the spine, with the force directed along the upward and lateral direction of the scapular spine, parallel to the long axis of the humerus, and with the humerus at a 140-degree elevation angle [ 55 ]. Serratus Anterior Scapular abduction is the scapular movement during SA contraction. Following the description by Kendall et al., the participant’s elbow is flexed at 90 degrees, and the HHD resistance is applied along the long axis of the humerus to the ulna at the olecranon process [ 56 ]. Due to the inherent instability of this test and the potential involvement of the triceps brachii, the examiner should place the other hand on the participant’s triceps to monitor via visual inspection and palpation, ensuring that the triceps does not generate force during the SA muscle test. 3 Result All participants (100%) completed the treatment in this study. There were no significant differences in age, height, weight, FHA, RSD, NDI, VAS scores, and the strength of MT, LT, and SA at baseline between the control group, BE group, and NCBE group (P > 0.05). The demographic and general characteristics of the three groups at baseline are shown in Table 1 . Table 1 Demographic and Baseline Characteristics of Participants, Including Age, Height, and Weight Variable Control group (Mean ± SD) BE group (Mean ± SD) NCBE group (Mean ± SD) T Sig Age 16.07 ± 0.70 175.67 ± 5.37 67.27 ± 8.27 0.82 0.45 Height 15.87 ± 0.74 176.13 ± 5.97 66.02 ± 7.91 0.09 0.92 Weight 15.73 ± 0.70 176.53 ± 5.68 68.37 ± 12.86 0.21 0.81 Note : NCBE: Neuromuscular combined with biomechanical exercise; BE: Biomechanical exercise alone. Intra-group Comparisons were conducted using t-tests; the findings are shown in Table 2 . At the End of Week 4 : Compared to pre-intervention levels, both the BE and NCBE groups demonstrated significant improvements in all assessment indicators (FHA: p < 0.05; RSD: p < 0.05; NDI: p < 0.05; VAS Score: p < 0.05; the strength of MT, LT, and SA: p 0.05). At the End of Week 8 : When compared to pre-intervention, the BE and NCBE groups continued to show significant improvements in all assessed indicators (FHA: p < 0.05; RSD: p < 0.05; NDI: p < 0.05; VAS Score: p < 0.05; the strength of MT, LT, and SA: p 0.05). Comparison Between Week 4 and Week 8 : From the end of Week 4 to the end of Week 8, the BE and NCBE groups experienced further significant improvements in all indicators (FHA: p < 0.05; RSD: p < 0.05; NDI: p < 0.05; VAS Score: p < 0.05; the strength of MT, LT and SA: p 0.05). Table 2 Comparison of FHA, RSD, NDI, VAS scores, and the strength of MT, LT, and SA in participants before the intervention, after the 4th week, and 8th week using dependent t-test Variable Group Number Pre-intervention After 4th week After 8th week FHA Control group 15 48.37 ± 2.39 48.63 ± 2.53 48.85 ± 2.86 BE group 15 48.49 ± 3.10 46.11 ± 1.39a* 43.31 ± 2.17bc* NCBE group 15 49.60 ± 3.49 45.02 ± 2.45a* 39.85 ± 2.46bc*# RSD Control group 15 72.63 ± 9.60 72.10 ± 8.47 71.78 ± 11.03 BE group 15 72.48 ± 9.89 63.92 ± 8.06a* 54.63 ± 9.85bc* NCBE group 15 74.24 ± 10.52 61.92 ± 6.87a* 47.83 ± 5.69bc* NDI Control group 15 15.66 ± 3.75 15.94 ± 3.90 16.36 ± 4.51 BE group 15 16.80 ± 4.74 12.65 ± 3.77a* 7.97 ± 3.14bc* NCBE group 15 15.66 ± 4.88 10.65 ± 3.34a* 4.50 ± 1.95bc*# VAS scores Control group 15 50.47 ± 7.45 52.07 ± 5.23 51.80 ± 4.83 BE group 15 48.87 ± 7.01 42.47 ± 6.61a* 35.00 ± 5.92bc* NCBE group 15 47.60 ± 8.57 38.40 ± 6.80a* 25.73 ± 6.78bc*# MT Control group 15 5.86 ± 0.44 5.90 ± 0.71 5.77 ± 0.86 BE group 15 5.75 ± 0.75 7.44 ± 0.88a* 9.11 ± 1.16bc* NCBE group 15 5.77 ± 0.64 8.19 ± 0.92a*# 11.43 ± 1.40bc*# LT Control group 15 5.78 ± 0.50 6.02 ± 0.56 5.99 ± 0.59 BE group 15 5.57 ± 0.46 7.30 ± 0.72a* 9.18 ± 1.26bc* NCBE group 15 5.62 ± 0.49 8.16 ± 1.04a*# 11.15 ± 1.27bc*# SA Control group 15 7.96 ± 1.45 7.87 ± 1.50 7.58 ± 1.55 BE group 15 7.68 ± 1.50 9.40 ± 1.55a* 11.36 ± 1.56bc* NCBE group 15 8.19 ± 1.80 10.76 ± 1.55a*# 15.05 ± 1.62bc*# Note : a: Within-group comparison between Week 4 and Pre-intervention (p < 0.05); b: Within-group comparison between Week 8 and Pre-intervention (p < 0.05); c: Within-group comparison between Week 8 and Week 4 (p < 0.05); *: Comparison between the NCBE/BE groups and the Control group (p < 0.05); #: Comparison between the NCBE group and the BE group (p < 0.05). Inter-group Comparisons were conducted using One-way ANOVA and Post-hoc Tukey’s test, and these findings are detailed in Tables 3 and 4 . At the End of Week 4: One-way ANOVA revealed significant differences among the groups regarding FHA (p < 0.05), RSD (p < 0.05), NDI (p < 0.05), VAS Score (p < 0.05), and the strength of MT, LT, and SA (p < 0.05). Post-hoc Tukey’s test indicated that, at the end of Week 4, the BE and NCBE groups had significantly better outcomes than the Control group in all measured indicators (FHA: p < 0.05; RSD: p < 0.05; NDI: p < 0.05; VAS Score: p < 0.05; the strength of MT, LT and SA: p < 0.05). Notably, the BE and NCBE groups differed significantly only in the strength of the MT, LT, and SA (P < 0.05), with no significant differences observed in other indicators (FHA: p = 0.371; RSD: p = 0.763; NDI: p = 0.306; VAS Score: p = 0.188). At the End of Week 8: The one-way ANOVA results indicated significant differences among the groups concerning FHA (p < 0.05), RSD (p < 0.05), NDI (p < 0.05), VAS Score (p < 0.05), and the strength of MT, LT and SA (p < 0.05). Post-hoc Tukey’s test showed that, at the end of Week 8, the BE and NCBE groups had significantly better outcomes than the Control group in all measured indicators (FHA: p < 0.05; RSD: p < 0.05; NDI: p < 0.05; VAS Score: p < 0.05; the strength of MT, LT and SA: p < 0.05). Comparisons between the BE and NCBE groups revealed significant differences in all indicators except for RSD (p = 0.116), which included FHA (p < 0.05), NDI (p < 0.05), VAS Score (p < 0.05), and the strength of the MT (p < 0.05), LT (p < 0.05), and SA (p < 0.05). Table 3 One-way ANOVA results were performed for FHA, RSD, NDI, VAS scores, the strength of MT, LT, and SA after 4th week, and after 8th week of different groups Variable Time Comparison Sum of Squares Degrees of Freedom Mean Square F-value Significance FHA after 4th week Inter-group 103.105 2 51.553 10.756 < 0.001* Intra-group 201.307 42 4.793 Total 304.412 44 after 8th week Inter-group 619.286 2 309.643 49.168 < 0.001* Intra-group 264.504 42 6.298 Total 883.790 44 RSD after 4th week Inter-group 873.372 2 436.686 7.125 0.002* Intra-group 2574.219 42 61.291 Total 3447.591 44 after 8th week Inter-group 4583.525 2 2285.288 27.323 < 0.001* Intra-group 3512.722 42 83.640 Total 8096.247 44 NDI after 4th week Inter-group 214.270 2 107.135 7.921 0.001* Intra-group 568.033 42 13.525 Total 782.303 44 after 8th week Inter-group 1115.627 2 557.814 49.236 < 0.001* Intra-group 475.830 42 11.329 Total 1591.457 44 VAS scores after 4th week Inter-group 1477.378 2 738.689 18.892 < 0.001* Intra-group 1642.267 42 39.102 Total 3119.644 44 after 8th week Inter-group 5237.911 2 2618.956 75.374 < 0.001* Intra-group 1459.333 42 34.746 Total 6697.244 44 MT after 4th week Inter-group 41.172 2 20.586 29.110 < 0.001* Intra-group 29.702 42 0.707 Total 70.874 44 after 8th week Inter-group 243.100 2 121.550 89.974 < 0.001* Intra-group 56.740 42 1.351 Total 299.840 44 LT after 4th week Inter-group 34.751 2 17.376 27.178 < 0.001* Intra-group 26.852 42 0.639 Total 61.603 44 after 8th week Inter-group 204.040 2 102.020 86.626 < 0.001* Intra-group 49.464 42 1.178 Total 253.503 44 SA after 4th week Inter-group 62.767 2 31.384 13.359 < 0.001* Intra-group 98.672 42 2.349 Total 161.439 44 after 8th week Inter-group 417.561 2 208.780 84.051 < 0.001* Intra-group 104.327 42 2.484 Total 521.887 44 Note : * indicates that the difference in means is statistically significant (p < 0.05). Table 4 Tukey’s test findings to examine the differences between different groups in FHA, RSD, NDI, VAS scores, the strength of MT, LT, and SA after the 4th week, and after 8th week Variable Time Group I Group J Mean Difference (I-J) Standard Error Significance FHA after 4th week Control group BE group 2.5267* 0.7994 0.008* NCBE group 3.6133* 0.7994 < 0.001* BE group NCBE group 1.0867 0.7994 0.371 after 8th week Control group BE group 5.5467* 0.9163 < 0.001* NCBE group 9.0067* 0.9163 < 0.001* BE group NCBE group 3.4600* 0.9163 0.001* RSD after 4th week Control group BE group 8.17733* 2.85869 0.018* NCBE group 10.18667* 2.85869 0.003* BE group NCBE group 2.00933 2.85869 0.763 after 8th week Control group BE group 17.14933* 3.33945 < 0.001* NCBE group 23.95267* 3.33945 < 0.001* BE group NCBE group 6.80333 3.33945 0.116 NDI after 4th week Control group BE group 3.29267* 1.34286 0.047* NCBE group 5.29267* 1.34286 < 0.001* BE group NCBE group 2.00000 1.34286 0.306 after 8th week Control group BE group 8.39333* 1.22905 < 0.001* NCBE group 11.86000* 1.22905 < 0.001* BE group NCBE group 3.46667* 1.22905 0.020* VAS scores after 4th week Control group BE group 9.600* 2.283 < 0.001* NCBE group 13.667* 2.283 < 0.001* BE group NCBE group 4.067 2.283 0.188 after 8th week Control group BE group 16.800* 2.152 < 0.001* NCBE group 26.067* 2.152 < 0.001* BE group NCBE group 9.267* 2.152 < 0.001* MT after 4th week Control group BE group -1.54733* 0.30707 < 0.001* NCBE group -2.29733* 0.30707 < 0.001* BE group NCBE group -0.75000* 0.30707 0.049* after 8th week Control group BE group -3.33667* 0.42441 < 0.001* NCBE group -5.66333* 0.42441 < 0.001* BE group NCBE group -2.32667* 0.42441 < 0.001* LT after 4th week Control group BE group -1.27600* 0.29196 < 0.001* NCBE group -2.13933* 0.29196 < 0.001* BE group NCBE group -0.86333* 0.29196 0.014* after 8th week Control group BE group -3.19067* 0.39627 < 0.001* NCBE group -5.16867* 0.39627 < 0.001* BE group NCBE group -1.97800* 0.39627 < 0.001* SA after 4th week Control group BE group -1.52867* 0.55968 0.024* NCBE group -2.89133* 0.55968 < 0.001* BE group NCBE group -1.36267* 0.55968 0.049* after 8th week Control group BE group -3.78000* 0.57550 < 0.001* NCBE group -7.46133* 0.57550 < 0.001* BE group NCBE group -3.68133* 0.57550 < 0.001* Note : * indicates that the difference in means is statistically significant (p < 0.05). 4 Discussion The external manifestations of UCS include forward head posture, rounded shoulders, and thoracic kyphosis. These issues are primarily attributed to prolonged sedentary behavior, extended periods of desk work, poor lifestyle habits, and excessive exercise. From a biomechanical perspective, muscle strength and length imbalances are likely the primary causes of these problems. From a neuromuscular perspective, insufficient muscle activation may be a key factor. Extensive research has demonstrated that stretching exercises targeting the levator scapulae, upper trapezius, and other neck extensor muscles, along with the pectoral muscles, and strengthening exercises for the middle and lower trapezius, rhomboids and deep neck flexors, can effectively improve alignment in patients with UCS. For instance, Bae et al. [ 57 ] implemented a 4-week program of strength and stretching exercises for students with forward head posture; Hajihosseini et al. [ 58 ] applied a 6-week stretching and strengthening program for scapular muscles in participants with forward head posture; Hamidiyeh et al. [ 59 ] conducted an 8-week stretching and strengthening intervention for participants with thoracic kyphosis; Nitayarak and Charntaraviroj [ 60 ] implemented a 4-week strengthening program for UCS patients; Roddey et al. [ 61 ] applied a 2-week stretching intervention for individuals with forward head posture and rounded shoulders; and Yoo [ 62 ] employed a 2-week stretching program for patients with forward head posture. These interventions significantly improved key indicators, including forward head angle, rounded shoulder angle, and kyphotic angle. However, the aforementioned studies primarily focused on biomechanical exercises (strengthening and stretching) and lacked evaluations of neuromuscular exercise interventions for UCS. To achieve optimal correction of UCS, exercise programs should emphasize both biomechanical and neuromuscular factors [ 18 ]. In this study, to ensure the effectiveness of the interventions in the experimental groups and based on previous research findings, both the BE and NCBE groups were provided with biomechanical exercises. To address the gaps in prior research (i.e., the lack of studies integrating neuromuscular and biomechanical exercises for UCS) and to differentiate this study from existing research, the NCBE group received a combined neuromuscular and biomechanical exercise program. This design also allowed for a comparison of the effectiveness of NCBE versus BE alone in the intervention for UCS. Intervention Effects on Outcome Measurements 1. Analysis of Intervention Effects of NCBE and BE on Alignment, NDI, and VAS Scores Abnormal alignment is an external manifestation of UCS, while neck disability and neck pain represent its internal manifestations. Quantifying the severity of the forward head posture (FHP), rounded shoulders (RS), neck disability (ND), and neck pain (NP) are essential to assess the improvement of UCS. This study used the FHA, NDI, and VAS scores to quantify FHP, ND, and NP, respectively. Additionally, RSD was used to quantify the degree of RS in UCS patients, distinguishing it from traditional rounded shoulder angle measurement methods. The results of this study indicate that at the end of weeks 4 and 8 of intervention, both the BE and NCBE groups showed significant improvements in FHP, RS, ND, and NP. The FHP and RSD returned to normal levels (FHA < 45°; RSD < 5.6 cm). From a biomechanical perspective, the following factors may explain these improvements: First, restoring the length and health of the myofascial tissues reduces the pressure on pain-sensitive structures such as nerves and blood vessels [ 44 ]. This may stimulate the lymphatic system, promote fluid flow, reduce swelling, accelerate recovery, and improve blood circulation to the muscle tissues, facilitating the removal of waste products (e.g., lactic acid) and providing more oxygen and nutrients to the muscles. Second, stretching exercises restore muscles’ normal length and elasticity, improve joint range of motion, and reduce the pressure on joints from overly tense muscle groups [ 63 ]. Third, strength exercises enhance the strength and endurance of the upper back and deep neck muscles in UCS patients, improving the function of the upper limb diagonal muscles and providing more substantial support for maintaining proper spinal posture. This helps correct abnormal postures like FHP and RS, thereby restoring normal joint alignment [ 47 ] and relieving NP and ND caused by poor neck posture. Similar studies also reported comparable results. Shadi et al. [ 34 ] conducted a 6-week NASM-based corrective exercise program for 13–16-year-old UCS girls, while Abdolahzad et al. [ 36 ] applied a similar NASM-based correction program for female students. Both studies found significant improvements in FHP, rounded shoulder angle (RSA), and kyphosis, which is consistent with the results of this study. Additionally, Jeong et al. [ 64 ] applied a Telerehabilitation program combined with diaphragmatic breathing re-education and shoulder stability exercises, which led to significant improvements in FHA, the height of RS, NDI, and upper trapezius pain levels. Mahmood et al. [ 65 ] used conventional physical therapy combined with instrument-assisted soft tissue mobilization. Although their intervention methods differ from those used in this study, the underlying principles are similar, i.e., releasing and stretching tense muscles to promote local blood circulation, alleviate muscle swelling and pain, strengthen weak muscle groups, enhance endurance and muscle activation, improve muscle balance, and restore joint alignment. Additionally, the results of this study revealed that at the 8-week, the NCBE group showed greater improvement than the BE group in FHA, NDI, and VAS scores, except for the RSD. From a neuromuscular perspective, abnormal alignment can affect the static and dynamic positioning of the scapula, increasing pressure on the cervical spine. NCBE group’s posture correction exercises help UCS patients develop healthy postural habits for the cervical, thoracic, and lumbar spine, avoiding FHP, RS, and kyphosis in daily life. Over time, this allows the restoration of normal spinal curvature, reduces abnormal loading on intervertebral discs and surrounding soft tissues, and alleviates pain [ 31 ]. Moreover, previous research has demonstrated that muscle proprioceptive deficits are a potential factor contributing to neck pain, often due to insufficient scapular motor control [ 66 ]. Consciously controlling the scapular muscles may be necessary for improving proprioception and normalizing the resting position of the scapula [ 31 ]. The scapular motor control exercises in NCBE have the following benefits: First, they correct existing scapular dyskinesis in UCS patients, such as excessive anterior tilt or inadequate upward rotation of the scapula, ensuring the scapula follows the correct movement trajectory during daily activities and exercises. Second, electromyography (EMG) data show that scapular orientation exercises (SOE) can effectively increase the activation of muscles such as the middle trapezius (MT) and lower trapezius (LT) [ 29 ], creating a chain reaction with strength exercises. This results in a more significant increase in the strength of scapular stabilizers, rapidly restoring muscle balance and improving joint alignment. As a result, the NCBE group exhibited superior improvements in alignment, neck disability, and neck pain compared to the BE group. However, by the eighth week, the improvement in RSD was not significantly different between the NCBE and BE groups. This could be because the RSD in the NCBE group had already normalized by the end of the intervention, so the improvement in this measurement diminished over time. 2. Analysis of Intervention Effects of NCBE and BE on Scapular Muscle Strength UCS patients commonly exhibit weakness and insufficient activation of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA). However, most previous studies primarily focused on measuring outcomes such as joint alignment in the upper back and neck, as well as neck pain, such as forward head angle (FHA), rounded shoulder angle (RSA), neck disability index (NDI), and visual analog scale (VAS), with insufficient evidence regarding the improvement of muscle function. Therefore, to provide a more comprehensive analysis of the effects of UCS interventions, it is crucial to include the study’s evaluation of scapular muscle function. Currently, two main methods exist for evaluating scapular muscle function: measuring muscle strength or assessing muscle activation levels. Seidi et al. [ 18 ] utilized electromyography (EMG) to assess the activation of selected muscles, including the UT, MT, LT, and SA, to measure improved scapular muscle activation following intervention. Lynch et al. [ 67 ] used handheld dynamometry to assess the strength of scapular muscles to determine the effect of intervention on scapular muscle strength. Studies have shown that increased scapular muscle strength and activation correlate with alleviating UCS symptoms. Seidi et al. [ 18 ] implemented a CCEP exercise program based on a combination of neuromuscular and biomechanical principles. After 8 weeks of intervention, significant increases in the activation of MT, LT, and SA were observed. The results related to alignment (including FHA, RSA, and TKA) and movement patterns (scapular dyskinesis) also showed significant improvement, and the positive effects were maintained even after 4 weeks of discontinuation. Lynch et al. [ 67 ] conducted an 8-week scapular muscle stretching and strengthening program for participants with FHP and RS. Post-intervention, the participants exhibited significant increases in the strength of the MT, LT and SA, and there were notable improvements in FHA, RSA, neck pain, and neck disability. Nitayarak et al. [ 60 ] implemented a 4-week scapular stabilization training program for UCS patients, significantly improving scapular muscle strength and effectively alleviating UCS symptoms. The results of this study also indicated that both BE and NCBE interventions led to significant improvements in the strength of the MT, LT, and SA muscles and alleviation of UCS-related symptoms, consistent with previous studies, thereby further confirming the findings of prior research. However, a key difference in this study is that it demonstrated that at both 4 and 8 weeks, NCBE showed a more significant improvement in scapular muscle strength compared to BE alone. From a neuromuscular perspective, we hypothesize that this could be due to the synergistic effect between neuromuscular exercises (postural correction exercises and scapular motor control exercises) and scapular muscle strengthening exercises in the NCBE group. Postural correction exercises and scapular motor control exercises enhance scapular muscle activation [ 29 , 68 ]. With increased muscle recruitment, scapular muscle strengthening can maximize the strength improvement of the target muscles, resulting in a more significant effect on muscle strength than BE alone. Nevertheless, this study has certain limitations. The experimental subjects were all male secondary school students aged 15–18, which slightly limits the sample coverage (excluding all age groups, female or male participants outside the 15–18 age range). Additionally, although this study used a longitudinal design, the long-term effects of the intervention were not explicitly verified. Therefore, future studies could consider expanding the sample size, including participants from different age groups and both genders, and extending the longitudinal study duration to validate the sustainability of the intervention effects further and enhance the generalizability of the intervention. 5 Conclusion Neuromuscular combined with biomechanical scapular stabilizer exercises have demonstrated significant effectiveness in treating UCS symptoms in secondary school students, particularly in correcting poor alignment, improving neck pain and disability, and enhancing muscle strength. Compared to pure biomechanical exercise, this integrated approach additionally strengthens the development of postural habits, muscle activation, and motor patterns (through neuromuscular exercises), making it more effective in alleviating UCS symptoms. This approach combines the advantages of both factors. Given its safety, cost-effectiveness, ease of implementation, and good adaptability to secondary school students, it shows great potential for widespread application in clinical and school settings. Moreover, the control group in this study also confirmed that treatment of UCS through conventional physical activity alone, without corrective exercise, is ineffective. Overall, this study provides an important approach for preventing and treating UCS in secondary school students and offers valuable directions for future research. Declarations Ethics approval and consent to participate: Consent for publication : All authors agree to publish this paper. Competing interests: The authors declare that they have no competing interests. Author Contribution Author Contributions Statement：XMH conceptualized the study, designed the research, conducted the investigation, implemented the clinical trial interventions, measured the clinical trial results, curated the data, and wrote and revised the manuscript (primary contributor).GYB supervised the project, managed the project, and provided resources.XQ performed the clinical trial interventions and measured the clinical trial results.KW approved the final manuscript.All authors reviewed the manuscript.Order of authors' names：XMH is the first author, GYB is the second author, XQ is the third author, and KW is the corresponding author Data Availability Data is provided within the manuscript or supplementary information files. References Muscolino JE. Upper crossed syndrome. J Australian Traditional-medicine Soc. 2015;21:80. Janda V. Chapter 10 – Muscles and Motor Control in Cervicogenic Disorders. 2002. Phadke A, et al. 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Motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. J Shoulder Elbow Surg. 2013;22(4):e11–9. Barnes MF. The basic science of myofascial release: morphologic change in connective tissue. J Bodyw Mov Ther. 1997;1:231–8. Thigpen CA, et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. J Electromyogr Kinesiol. 2010;20(4):701–9. Harman K, Hubley Kozey CL, Butler HL. Effectiveness of an Exercise Program to Improve Forward Head Posture in Normal Adults: A Randomized, Controlled 10-Week Trial. J Man Manipulative Therapy. 2005;13:163–76. Firouzjah MH, Firouzjah E, Ebrahimi Z. The effect of a course of selected corrective exercises on posture, scapula-humeral rhythm and performance of adolescent volleyball players with upper cross syndrome. BMC Musculoskelet Disord. 2023;24(1):489. Ruivo RM, Pezarat-Correia P, Carita AI. Intrarater and interrater reliability of photographic measurement of upper-body standing posture of adolescents. J Manipulative Physiol Ther. 2015;38(1):74–80. Young IA et al. Psychometric properties of the Numeric Pain Rating Scale and Neck Disability Index in patients with cervicogenic headache. Cephalalgia, 2019(1). Lim H, et al. Cross-cultural Adaptation, Reliability, Validity, and Responsiveness of the Simplified-Chinese Version of Neck Disability Index. Spine (Phila Pa 1976). 2020;45(8):541–8. Saeterbakken AH, et al. Nordic walking and specific strength training for neck- and shoulder pain in office workers: a pilot-study. Eur J Phys Rehabil Med. 2017;53(6):928–35. Roberts D, Li F. The presentation and outcomes of shoulder pain in public hospital physiotherapy departments in NSW: an observational study. Physiother Theory Pract. 2014;30(5):299–305. Michener LA, et al. Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity. Phys Ther. 2005;85(11):1128–38. Kim T, et al. Reliability of scapular position and periscapular muscle strength tests in healthy subjects with forward neck and rounded shoulder posture. Isokinetics and Exercise Science; 2024. Hislop HJ, Montgomery J. Daniels and Worthingham's Muscle testing. elsevier ltd oxford; 2002. Kendall HO, McCreary EK, Kendall FP. Muscles, testing and function. 3rd ed. Baltimore: Williams & Wilkins; 1983. p. 326. Bae WS, et al. The effect of middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises in upper crossed syndrome. J Phys Ther Sci. 2016;28(5):1636–9. Journal PT. The Effects of Strengthening, Stretching and Comprehensive Exercises on Forward Shoulder Posture Correction. JOURNAL OF PHYSICAL TREATMENTS; 2014. 3. Hamidiyeh M, Naserpour H, Chogan M. Change in Erector Spinae Muscle Strength and Kyphosis Angle Following an Eight Weeks TRX Training in middle-age Men. 2021. Nitayarak H, Charntaraviroj P. Effects of scapular stabilization exercises on posture and muscle imbalances in women with upper crossed syndrome: A randomized controlled trial. J Back Musculoskelet Rehabil. 2021;34(6):1031–40. Heebner ML, Roddey TS. The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital. J Hand Therapy Official J Am Soc Hand Therapists. 2008;21(3):242–4. Yoo WG. Comparison of the effects of pectoralis muscles stretching exercise and scapular retraction strengthening exercise on forward shoulder. J Phys Ther Sci. 2018;30(4):584–5. Page P. Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports Phys Ther. 2012;7(1):109–19. Jeong GH, Lee BH. Effects of Telerehabilitation Combining Diaphragmatic Breathing Re-Education and Shoulder Stabilization Exercises on Neck Pain, Posture, and Function in Young Adult Men with Upper Crossed Syndrome: A Randomized Controlled Trial. J Clin Med, 2024. 13(6). Mahmood T, et al. Comparative effectiveness of routine physical therapy with and without instrument assisted soft tissue mobilization in patients with neck pain due to upper crossed syndrome. J Pak Med Assoc. 2021;71(10):2304–8. Espí-López GV, et al. Efficacy of a proprioceptive exercise program in patients with nonspecific neck pain: a randomized controlled trial. Eur J Phys Rehabil Med. 2021;57(3):397–405. Lynch SS, et al. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010;44(5):376–81. De Mey K, et al. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. 2013;16(1):65–70. Additional Declarations No competing interests reported. Supplementary Files Someexercisefigures.docx Table1Demographic.xlsx Table2Forwardheadangle.xlsx Table3Roundshoulderdistance.xlsx Table4Neckdisabilityindex.xlsx Table5Visualanalogscale.xlsx Table6Thestrengthofmiddletrapezius.xlsx Table7Thestrengthoflowertrapezius.xlsx Table8Thestrengthofserratusanterior.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5789540","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":400056685,"identity":"f537eff0-3ce8-4838-98ec-c1654b01c9fb","order_by":0,"name":"Xuanming Hu","email":"","orcid":"","institution":"Nanjing Sport Institute","correspondingAuthor":false,"prefix":"","firstName":"Xuanming","middleName":"","lastName":"Hu","suffix":""},{"id":400056686,"identity":"06c897b8-8bc3-4e68-b26b-c0dc4e6d9a6f","order_by":1,"name":"Guiying Bao","email":"","orcid":"","institution":"Tongliao Mongolian Medical Research 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16:21:10","extension":"xlsx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":11328,"visible":true,"origin":"","legend":"","description":"","filename":"Table7Thestrengthoflowertrapezius.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5789540/v1/35331ef7da162eb9687e36f6.xlsx"},{"id":73697311,"identity":"38fd4dd0-435b-469b-a9ce-1b4af38bdcfe","added_by":"auto","created_at":"2025-01-13 16:29:10","extension":"xlsx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":11793,"visible":true,"origin":"","legend":"","description":"","filename":"Table8Thestrengthofserratusanterior.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-5789540/v1/95c7927f8d062bb3903f0bf0.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Effect of Neuromuscular Combined with Biomechanical Scapular Stabilizer Muscle Corrective Exercises on Upper Crossed Syndrome in Chinese Secondary School Students: A Randomized Controlled Trial\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eIn 1979, neurologist Dr. Vladimir Janda first introduced the concept of Upper Crossed Syndrome (UCS), a muscular imbalance pattern involving the head and shoulder regions. UCS is commonly observed among individuals who spend prolonged periods sitting or working at a desk and have poor posture throughout the day [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This muscular imbalance manifests as tightness and shortening of the upper trapezius, pectoralis major, and pectoralis minor muscles. In contrast, the rhomboids, middle and lower trapezius, and serratus anterior muscles are passively stretched and weakened. These imbalances contribute to UCS-related symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProlonged sitting with poor posture is a significant contributing factor to UCS. Research indicates that as total sitting time increases, the degree of postural abnormality also rises, with each additional unit of weekly sitting time leading to a 75.1% increase in postural dysfunction scores [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Extended sitting causes fatigue in the lumbar extensors, making it difficult to maintain the natural spinal curvature. This poor posture may lead to underactivation of specific muscles and overactivation of others [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], ultimately resulting in habitual forward head posture, rounded shoulders, and thoracic kyphosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to academic pressures and prolonged use of electronic devices, sedentary behavior and screen time among Chinese adolescents have significantly increased in recent years. Studies show that Chinese adolescents spend an average of nearly 8 hours per daily sitting [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with screen time averaging 1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50 hours on school days and 2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.45 hours on weekends, which exceeds the World Health Organization (WHO) recommended 2-hour limit [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In China, secondary school students are a high-risk group for UCS. A 2019 study in Shanghai found that rounded shoulders and forward head posture were the most common postural abnormalities in secondary school students, with prevalence rates of 60.5% and 58.1%, respectively [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A 2020 study on middle school students in Nanjing reported that the most prominent postural issues were forward head posture and rounded shoulders, affecting 68% and 52% of students, respectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A 2022 posture screening in Beijing\u0026rsquo;s Xicheng District showed that 99.34% of first-year high school students exhibited forward head posture, and 60.9% had abnormal thoracic kyphosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe misalignment associated with UCS causes various problems for students: (1) Chronic neck and shoulder pain, often resulting in cervical spine disorders [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; (2) Functional abnormalities in the neck and shoulder region, such as narrowing of the subacromial joint capsule, which leads to shoulder impingement syndrome and disrupts daily activities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]; (3) Psychological issues, including lowered self-esteem and body image concerns due to altered posture [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; (4) Altered shoulder joint mechanics, placing excessive strain on the cervical-thoracic junction, C4-5 and T4 segments, and the shoulder, potentially causing angina and chest pain [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and negatively impacting respiratory efficiency and lung capacity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecondary school students are in a critical period of growth and development, during which their muscles and bones show significant plasticity. Their alignment is not only highly susceptible to the effects of poor habits but also responsive to appropriate interventions. However, due to academic pressures and limited time and energy, traditional, time-consuming treatments are often impractical for this group. To effectively address UCS in secondary school students, several key factors must be considered: First, given the widespread nature of posture problems among adolescents, interventions should be low-cost, portable, and applicable to a broad population; Second, as secondary school students are in a sensitive developmental phase, treatments must ensure safety and avoid any adverse effects on normal growth; Third, due to academic burdens, treatment plans should be simplified to minimize disruption to students\u0026rsquo; daily studies while ensuring efficacy; Fourth, poor posture in school students primarily results from altered muscle function [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Scapular stabilizer corrective exercise aims to enhance muscular function while adhering to the physiological load-bearing capacity of students. This approach is more effective than other methods, such as physical therapy, in improving posture, increasing joint mobility, and enhancing muscle flexibility, making it the preferred intervention [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, scapular stabilizer corrective exercises are generally based on two distinct theories: biomechanical factors and neuromuscular factors. From a biomechanical perspective, abnormal alignments in UCS are attributed to imbalances in muscle length and strength [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Exercises within this paradigm focus on restoring muscle balance by rehabilitating muscle length and strength to treat UCS. Conversely, from a neuromuscular standpoint, abnormal joint alignments in UCS are considered to stem from abnormalities in the nerves\u0026rsquo; control of muscles [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This approach emphasizes increasing exercise recruitment, establishing good movement patterns, and gradually forming exercise habits to restore normal joint positions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, traditional therapeutic approaches predominantly attribute functional abnormalities of UCS to biomechanical factors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], potentially overlooking other contributory factors such as those related to neuromuscular aspects [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Neglecting neuromuscular factors may result in limited therapeutic efficacy, and studies have indicated that isolated biomechanical exercises may not effectively improve abnormal alignment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, an integrative exercise strategy that combines biomechanical and neuromuscular approaches appears critical. This comprehensive method aims to optimize the function of scapular stabilizers from multiple dimensions, providing patients with a more thorough and effective therapeutic solution.\u003c/p\u003e \u003cp\u003eA randomized controlled trial (RCT) was conducted to address this gap. The primary objective was to evaluate neuromuscular effects combined with biomechanical exercise (NCBE) on UCS in secondary school students. The secondary objective was to compare NCBE with biomechanical exercise (BE) alone and to analyze the potential mechanisms underlying the treatment effects.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 1\u003c/strong\u003e \u003cp\u003eBoth the NCBE and BE will be effective in treating UCS in secondary school students.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 2\u003c/strong\u003e \u003cp\u003eThe NCBE will be more effective in treating UCS in secondary school students compared to BE.\u003c/p\u003e \u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThis study employed a randomized controlled trial (RCT) design to evaluate and compare the effects of neuromuscular combined with biomechanical scapular stabilizer exercises (NCBE) and purely biomechanical scapular stabilizer exercises (BE) on UCS in secondary school students. The study was conducted over 14 weeks, from July 10, 2024, to October 13, 2024, at a secondary school in Tongliao, China.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants and Eligibility Criteria\u003c/h2\u003e \u003cp\u003eThe sample size was determined using G*Power 3.1.9.2 software. Based on previous studies, the effect size was estimated to be 0.66 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We aimed to achieve 80% statistical power at a two-tailed significance level (α\u0026thinsp;=\u0026thinsp;0.05). The sample size calculation indicated that at least 39 participants were required to achieve the desired power. The target sample size was increased to 45 participants to account for potential dropout. These participants were randomly assigned to three groups, with 15 participants per group.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion Criteria\u003c/strong\u003e \u003cp\u003eSecondary school students aged 15\u0026ndash;18 years, with a forward head posture angle greater than 45\u0026deg; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], a rounded shoulder distance greater than 5.6 cm [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], mild to moderate pain (VAS score 10\u0026ndash;60 mm) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and willingness to participate in the trial.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion Criteria\u003c/strong\u003e \u003cp\u003eParticipants with a history of disease, fractures, surgeries, joint issues, spinal injuries, abnormal BMI, diagnosed muscular pathology, cervical soft tissue fractures, or those unable to attend at least three exercise sessions per week.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eA total of 45 male secondary school students aged 15\u0026ndash;18 years who met the inclusion and exclusion criteria for UCS were recruited from the secondary school. All participants were informed of the study\u0026rsquo;s purpose, procedures, and potential risks before participation. Written informed consent was obtained from both the participants and their parents. Participants were informed of their right to withdraw from the study at any time without facing any adverse consequences. The study design was approved by the Ethics Committee of Nanjing Sport Institute(Approval No: [RT-2024-13]), and it adhered to the ethical principles outlined in the Declaration of Helsinki (2013).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Randomization\u003c/h2\u003e \u003cp\u003ePrior to randomization, all potential participants underwent eligibility assessments. A computer-generated randomization list was used, employing block randomization to ensure participants were allocated in a 1:1:1 ratio to the neuromuscular combined with the biomechanical exercise group (NCBE group), the biomechanical exercise group (BE group), and the control group. The block size was kept confidential to prevent the prediction of group allocation. An independent statistician was responsible for the randomization process and was kept blinded by the trial personnel to ensure that group assignments were concealed. Statisticians recorded the group assignments for each participant, stored them in a secure database, and verified the randomization results for each stratification combination. To prevent selection bias, allocation concealment was implemented. Specifically, the generated random sequence was sealed in opaque envelopes; each labelled only with the participant\u0026rsquo;s ID. After completing baseline assessments, the researchers opened the envelopes sequentially according to participant IDs to determine their group allocation. Subsequently, the 45 participants were randomly assigned to one of the three groups: the control group, the BE group, or the NCBE group, with 15 participants in each group.\u003c/p\u003e \u003cp\u003eBaseline data were collected for all participants, including age, height, weight, and UCS-related measurements (including forward head angle (FHA), rounded shoulder distance (RSD), neck disability index (NDI), visual analog scale (VAS) score, and strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) ). An analysis of variance (ANOVA) was conducted to compare baseline data among the groups to ensure no significant differences in baseline characteristics. Adjustments were made using covariates or other statistical methods if significant differences were detected. The final statistical analysis showed no significant differences across groups regarding age, height, weight and UCS-related measurements (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating successful baseline equivalence.\u003c/p\u003e \u003cp\u003e We adhered to the CONSORT guidelines and created a flowchart (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) detailing the entire process, from eligibility screening, enrollment, randomization, intervention, and outcome measurements.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Intervention\u003c/h2\u003e \u003cp\u003eRestoring the degree of muscle activation is crucial in neuromuscular interventions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Biomechanical interventions focus on restoring the muscle length of overactive muscles and strengthening weak muscles [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Current neuromuscular treatments include electromyographic biofeedback training, muscle energy techniques (MET), proprioceptive neuromuscular facilitation (PNF) training, scapular motor control exercises, and postural correction exercises. Biomechanical interventions primarily involve myofascial release, stretching, and strength exercise.\u003c/p\u003e \u003cp\u003eIn neuromuscular exercises, Mottram et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] implemented Scapular-Oriented Exercises (SOE) and found that SOE significantly improved scapular positioning and activation of the scapular muscles. Wegner et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] conducted postural correction exercises for patients with neck pain, effectively adjusting the activity pattern of the trapezius muscles and bringing them closer to the performance of healthy individuals. Cools et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] combined postural correction exercises with scapular movement control, encouraging participants to frequently practice correct postural habits in daily life, thereby fostering long-term behavioral change [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Seidi et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] emphasized the importance of considering neuromuscular factors when treating UCS, stressing the need to focus not only on external factors, such as chest elevation, shoulder depression, and chin retraction but also on internal factors, specifically the precise control of scapular positioning by the scapular muscles.\u003c/p\u003e \u003cp\u003eIn biomechanical exercises, Sasun et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] demonstrated that myofascial rolling exercises were more effective than isometric relaxation techniques in alleviating pain and improving posture in UCS patients. Shadi et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], based on the National Academy of Sports Medicine (NASM) principles, developed a corrective exercise program that included stretching and strength exercises. After 6 weeks of intervention, this program showed superior results compared to Pilates or the Alexander Technique, particularly in correcting UCS-related abnormal alignments. The NASM Corrective Exercise Specialist (CES) certification program emphasizes assessing and managing movement dysfunctions, muscle imbalances, and posture-related issues [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Existing evidence supports the significant efficacy of NASM-based corrective exercises in treating UCS [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the above research findings, this study aims to develop a modified exercise program that combines neuromuscular and biomechanical approaches, utilizing portable and easily applicable student exercises. The neuromuscular component focuses on postural corrective exercises and scapular motor control exercises. In contrast, the biomechanical component follows NASM guidelines and focuses on enhancing the function of the scapular stabilizer muscles, which includes content such as myofascial release, stretching exercises, and strength exercises. The specific components of the exercise program are outlined as follows:\u003c/p\u003e \u003cp\u003ePostural Correction Exercises: Re-educating the neutral spinal position and correcting cervical, thoracic, and lumbar postures to help patients establish correct postural habits [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScapular Motor Control Exercises: Proprioceptive training for the scapular muscles aimed at improving neuromuscular control, retraining muscle recruitment patterns, and enhancing scapular movement patterns [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMyofascial Release: Myofascial pain is a condition caused by trigger points (TrP) within muscles or fascia. Trigger points are characterized by localized tenderness and excessive stimulation. Myofascial release involves gradually applying pressure to active trigger points (MTrP) until the patient feels a release of pressure, which helps elongate muscle fibers and increase the range of motion while reducing muscle tension [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStretching Exercises: Static stretching involves slowly stretching the muscle to a specified position and holding it for some time. This technique can help alleviate pain, disability, and increase range of motion (ROM), especially for patients with cervical disc disease or non-specific pain [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrength Exercises: Using external resistance (resistance bands) to enhance the strength and endurance of the scapular muscles, thus improving joint stability.\u003c/p\u003e \u003cp\u003eTo ensure the objectivity of the exercise program design, we interviewed five experts, including two sports medicine specialists and three kinesiology experts, who evaluated the selected exercises for treating UCS in secondary school students. Based on their feedback, we confirmed the feasibility of implementing the program.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Neuromuscular Exercises\u003c/h2\u003e \u003cp\u003ePostural Correction Exercises Followed by Scapular Motor Control Exercises.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePostural Correction Exercises\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e Principle: During the first 4 weeks, the therapist assists the participants in correcting their posture; after the 4th week, participants are encouraged to correct their posture independently, with the therapist observing and supervising.\u003c/p\u003e \u003cp\u003eThe intervention is divided into two steps:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 1\u003c/strong\u003e \u003cp\u003eAchieving neutral lumbar spine and pelvis position through tactile feedback and verbal cues.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 2\u003c/strong\u003e \u003cp\u003e Using verbal prompts such as \u0026ldquo;chest up, shoulders down, chin in\u0026rdquo; to help participants adjust their thoracic and cervical postures.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eScapular Motor Control Exercises\u003c/b\u003e:\u003c/p\u003e \u003cp\u003ePrinciple: During the first 4 weeks, the therapist assists the participants in improving scapular movement control; after the 4th week, participants are encouraged to independently control scapular movement, with the therapist observing and supervising.\u003c/p\u003e \u003cp\u003eThe intervention is divided into three steps:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStep 1\u003c/strong\u003e \u003cp\u003eExplain and demonstrate the scapula\u0026rsquo;s optimal resting position and movement patterns using verbal instructions and video presentations, ensuring students internalize the correct scapular positioning.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003eStep 2\u003c/b\u003e: The therapist uses manual contact and verbal cues to guide participants in consciously positioning the scapula in the optimal location [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The following guidelines are followed: Visual cues: The scapula should be positioned between the second and seventh ribs in the posterior thoracic region [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Tactile cues: The relative position of the scapula can be assessed through palpation of the spine and scapula. The optimal position is when the superior angle of the scapula is aligned with the spinous process of T2 or T3, the root of the scapular spine aligns with the spinous process of T3 or T4, and the inferior angle aligns with T7, T8, or T9. However, it may descend as low as T10 [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. It is important to note that the scapula is not positioned on the frontal plane of the thorax but is instead positioned at a 30-degree angle relative to the thorax [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 3\u003c/b\u003e: Scapular Orientation Exercises: The therapist uses manual contact and verbal cues to guide participants in performing scapular movements autonomously, including protraction, retraction, elevation, depression, upward rotation, downward rotation, internal rotation, and external rotation, to facilitate proper scapular motion [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Biomechanical Exercises\u003c/h2\u003e \u003cp\u003eThe sequence of exercises is as follows: fascia release, stretching exercises, and strengthening exercises.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFascia Release (Progressive Pressure Release)\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePrinciple: Slowly roll the fascia ball over the target muscle groups, focusing on areas of muscle soreness and trigger points. The ball may be held still or rolled repeatedly over the painful areas until tension and pain are alleviated. In the first four weeks, each exercise is repeated 3 times, with each repetition lasting 90 seconds. After the fourth week, gradually increase the pressure applied to the muscle fascia, ensuring the resistance is not excessive. Each exercise is repeated 4 times, with each repetition lasting 120 seconds. After 90\u0026ndash;120 seconds of fascia release, the tissue undergoes histological changes, and after several releases, the tissue becomes softer and more flexible [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e \u003cb\u003e1. Fascia Release for the Neck Extensor Muscles\u003c/b\u003e \u003c/p\u003e\u003cp\u003eStand with your back against the wall and place the fascia ball on the posterior neck muscles. Use body weight to gradually increase the ball\u0026rsquo;s pressure on the muscle, rolling and pressing along the direction of the upper trapezius and levator scapula muscles.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Fascia Release for the Chest Muscles\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eStand facing the wall and place the fascia ball on the chest. Ensure the ball is in direct contact with the pectoral muscles, using body weight to apply pressure to the muscles gradually. Roll and press along the fiber direction of the pectoralis major and minor.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStretching Exercises\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePrinciple: Stretching should be slow and smooth, avoiding rapid or forceful movements to prevent muscle strain. Gradually increase the stretch range until a mild stretch is felt, but not pain. In the first 4 weeks, each exercise is repeated 3 times, holding each stretch for 20 seconds. After the fourth week, each exercise is repeated 4 times, holding each stretch for 20 seconds. The following presentation of stretching exercises focuses on the right side of the body.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1. Stretching the Pectoralis Major and Minor\u003c/b\u003e:\u003c/p\u003e \u003cp\u003ePlace the right hand or forearm on a door frame, with the elbow slightly higher than the shoulder height. Step forward with one foot and push the body forward to stretch the chest muscles.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStretching the Upper Trapezius and Levator Scapulae\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eGrasp the head with the left hand and hold a fixed object with the right hand. Gently pull the head downward to the left side while slightly rotating the head to the right.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengthening Exercises\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePrinciple: Ensure that the target muscle groups are fully engaged during each movement to avoid compensation by other muscles. In the first 4 weeks: Perform three sets of each exercise, with 8\u0026ndash;10 repetitions per set. After the fourth week: Gradually increase resistance based on individual strength levels. Perform four sets of each exercise, with 12\u0026ndash;15 repetitions per set.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(1) Bent-Over Y-Raise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting Position: Stand with your body bent forward at a 30\u0026deg; to 45\u0026deg; angle to the floor, keeping your back straight. Flex both arms forward at a 90\u0026deg; angle, positioned in front of your chest.\u003c/p\u003e \u003cp\u003eMovement: Use the scapular muscles to flex both arms to 180\u0026deg;, forming a \u0026ldquo;Y\u0026rdquo; shape with your torso and thumbs pointing toward the ceiling.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(2) Bent-Over W-Exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting Position: Stand with your body bent forward at a 30\u0026deg; to 45\u0026deg; angle to the floor, keeping your back straight. Flex your upper arms with your elbows at a 90\u0026deg; angle, positioning your forearms parallel to your chest in front of your body.\u003c/p\u003e \u003cp\u003eMovement: Initiate the movement by retracting the scapula, pulling them inward, which will bring your arms and torso into a \u0026ldquo;W\u0026rdquo; shape. During the movement, focus on the contraction of the upper back muscles and the tension as the scapula comes closer together.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(3) Resistance Band T-Extension\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting position: Stand with the torso in a neutral position. Arm flex to 90\u0026deg;, positioned in front of the chest.\u003c/p\u003e \u003cp\u003eMovement: Maintain the arms at 90\u0026deg; of shoulder flexion and move the shoulder joint into abduction in the horizontal plane.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(4) Resistance Band External Rotation Exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting position: Stand with feet shoulder-width apart, holding the resistance band with both hands. Elbows were bent at 90\u0026deg;, with the upper arms close to the body and forearms parallel to the ground.\u003c/p\u003e \u003cp\u003eMovement: Contract the shoulder muscles to externally rotate the forearms, ensuring the upper arm is close to the torso throughout the movement.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(5) Foam Roller Wall Slide\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting Position: Stand facing a wall, with forearms at shoulder width apart and the foam roller at eye level. Flex the elbows and press the foam roller against the wall.\u003c/p\u003e \u003cp\u003eMovement: Exhale and press the foam roller upward, bringing the arms overhead while feeling the serratus anterior contract to rotate the scapulae upwardly. Inhale as you press the foam roller downward, feeling the downward rotation of the scapulae. Repeat for four sets of 20 repetitions, ensuring not to shrug the shoulders during the upward movement.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(6) Wide-Grip Resistance Band Row\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStarting position: Stand with feet shoulder-width apart, holding the resistance band with both hands, hands positioned wider than shoulder-width. Both arms flexed to a certain angle with elbows extended and core engaged.\u003c/p\u003e \u003cp\u003eMovement: Retract the scapula towards the spine, bending the elbows and pulling the resistance band towards the sides of the shoulders. During the pull, avoid over-relying on the arms and focus on activating the upper back muscles (such as the middle trapezius and rhomboids) for the movement.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(7) Deep Cervical Flexor Exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStudents were instructed to stand or sit with the torso in a neutral position, gently tucking the chin toward the neck. Ensure that the \u0026ldquo;occiput-neck-back\u0026rdquo; forms a straight line. Attach the middle of the resistance band to the back of the head.\u003c/p\u003e \u003cp\u003eMovement: then they grasp the ends of the resistance band with both hands and pull forward, resisting the band\u0026rsquo;s pull as the head extends backwards against the resistance. This isometric contraction maintains a straight line with the head, neck, and back. In the first 4 weeks, they were instructed to repeat three sets, each lasting 30 seconds. After the fourth week, repeat four sets, each lasting 1 minute.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eNote\u003c/strong\u003e \u003cp\u003e(1) Two qualified rehabilitation coaches trained the BE and NCBE groups. Both coaches received training for this experiment before the trial and were proficient in the required corrective exercise techniques. During the training, a therapist with over 10 years of experience in physical therapy supervised and guided the participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e(2) In the first week before the experiment officially began, participants in both the NCBE and BE groups were taught the principles and the correct execution of the exercises.\u003c/p\u003e \u003cp\u003e(3) Corrective exercises for the BE and NCBE groups were conducted in an open training environment, with sessions occurring three times per week for a total of 8 weeks. After the fourth week of exercise intervention, participants who could complete the exercises without difficulty or whose symptoms did not worsen progressed to the next level of exercise. If participants experienced pain or physical discomfort during the experiment, they would stop the training or withdraw from the study.\u003c/p\u003e \u003cp\u003e(4) For the NCBE group, the neuromuscular corrective exercises were performed first, followed by the biomechanical corrective exercises.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Outcome Measures\u003c/h2\u003e \u003cp\u003eOn weeks 4 and 8 (post-intervention), measurements were taken before the intervention. Three physical therapists, each trained in the trial protocol, performed the measurements for all three groups. The measurements were supervised by a therapist with over 10 years of experience in physical therapy. The three physical therapists independently assessed the control, BE, and NCBE groups while remaining blinded to the group assignments. The outcome measures included a comprehensive assessment of the participants\u0026rsquo; age, height, and weight, as well as evaluations of forward head posture, rounded shoulder posture, neck disability, neck pain, and isometric strength of the scapular muscles(middle trapezius, lower trapezius, serratus anterior). The specific methods for measuring each outcome are as follows:\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.5.1 Measurement of Forward Head Posture\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe photographic measurement method was used, with the digital camera placed 265 cm away from the wall and its height adjusted to the level of the participant\u0026rsquo;s right shoulder. The participant was asked to perform three forward bends and three overhead arm raises in this position and then return to a comfortable and natural standing position. Three photos were taken from the participant\u0026rsquo;s right side [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and these images were imported into AutoCAD to measure the forward head angle (FHA) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The angle between the line from the ear tragus to C7 and the vertical line was measured (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and an angle greater than 45\u0026deg; was considered abnormal [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The average of these three photos was recorded. Ruivo et al. reported the intra- and inter-rater reliability of photographic measurements of forward head posture as ICC\u0026thinsp;=\u0026thinsp;0.87 and 0.66, respectively [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.5.2 Measurement of Round Shoulder\u003c/h2\u003e \u003cp\u003eRound shoulder refers to the forward displacement of the acromion relative to the spinous process of the seventh cervical vertebra. In this study, the degree of the round shoulder is quantified by the round shoulder distance (RSD). One end of the caliper is placed at the anterior acromion point. In contrast, the other end is positioned at the same coronal plane as the C7 vertebra and at the same sagittal plane as the anterior acromion. A built-in spirit level confirms that the caliper is perfectly horizontal, i.e., parallel to the ground. Once the caliper is correctly aligned, the straight-line distance between the two ends is recorded as the measurement result. The reliability of this measurement technique, with an ICC value of 0.91, is clinically significant [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.5.3 Measurement of Neck Disability\u003c/h2\u003e \u003cp\u003eNeck disability was measured using the neck disability index (NDI), a valid and reliable questionnaire comprising 10 items related to pain intensity, personal care, lifting, reading, concentrating, work, driving, sleeping, recreation, and headaches. Each question has six possible answers, with scores ranging from 0 (no pain or functional limitation) to 5 (severe pain and maximum limitation). Patients were required to select the response that most accurately reflects their current condition.\u003c/p\u003e \u003cp\u003eThe calculation method is as follows: Total score = \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\text{S}\\text{u}\\text{m}\\:\\text{o}\\text{f}\\:\\text{s}\\text{c}\\text{o}\\text{r}\\text{e}\\text{s}\\:\\text{f}\\text{o}\\text{r}\\:\\text{a}\\text{l}\\text{l}\\:\\text{i}\\text{t}\\text{e}\\text{m}\\text{s}}{\\text{N}\\text{u}\\text{m}\\text{b}\\text{e}\\text{r}\\:\\text{o}\\text{f}\\:\\text{c}\\text{o}\\text{m}\\text{p}\\text{l}\\text{e}\\text{t}\\text{e}\\text{d}\\:\\text{i}\\text{t}\\text{e}\\text{m}\\text{s}\\times\\:5}\\times\\:100\\text{ %}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThe scores are presented as a percentage, with higher scores indicating greater disability. The interpretation of scores is as follows: 0\u0026ndash;20% indicates mild disability, 21%-40% indicates moderate disability, 41%-60% indicates severe disability, 61%-80% indicates very severe disability, and 81%-100% indicates complete disability [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This study used the Simplified Chinese version of the NDI, which has demonstrated excellent internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.92) and good test-retest reliability (ICC2,1\u0026thinsp;=\u0026thinsp;0.85) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.5.4 Measurement of Neck Pain Intensity\u003c/h2\u003e \u003cp\u003eA 100-mm visual analog scale (VAS) was used to assess the intensity of neck pain in participants. The scale is anchored by \u0026ldquo;0\u0026rdquo; representing \u0026ldquo;no pain\u0026rdquo; and \u0026ldquo;100\u0026rdquo; representing \u0026ldquo;the most severe pain.\u0026rdquo; Participants were instructed to mark the point on the 100-mm line representing the most severe pain they experienced in the past 24 hours. The distance from the left end of the scale to the marked point was then measured and recorded in millimeters [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.5.5 Measurement of Strength of Scapular Muscles\u003c/h2\u003e \u003cp\u003eManual muscle testing (MMT) was used to measure the strength of scapular muscles, utilizing a handheld dynamometer (HHD). The HHD used in this study was the Hoggan MicroFET2\u0026trade;, a tool for quantifying muscle strength. During scapular muscle testing, the HHD provides reliable isometric muscle force measurements for the middle trapezius, lower trapezius, and serratus anterior muscles. The inter-rater reliability coefficient for the measurements ranged from 0.89 to 0.96, indicating excellent reliability [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe principle of MMT involves applying resistance in the opposite direction of the muscle contraction [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. During the measurement, the primary target muscle should exhibit the highest activity level compared to secondary or stabilizing muscles. The HHD was positioned at the midpoint of the specific muscle being tested. Resistance was gradually applied through the HHD until the force exerted by the examiner was equal to the force exerted by the participant, achieving maximal isometric contraction. The strength of the target muscle during maximal isometric contraction was measured [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. If force balance was not achieved between the examiner and participant, or if the participant experienced pain, the test was stopped, and a brief rest period was taken before resuming. A 2-minute rest was allowed between each muscle strength test. The strength test for the dominant muscle was repeated three times, and the average of the three maximal strength values was used for data analysis, with measurements recorded in kilograms [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The students in the control and BE groups and three different examiners tested the NCBE group. These three examiners received training on the muscle testing procedures for this study prior to the tests, which a therapist supervised with approximately 10 years of experience in physical therapy.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMiddle Trapezius\u003c/strong\u003e \u003cp\u003eScapular retraction is the movement of the scapula during MT contraction. According to Hislop et al., the resistance from the HHD is applied to the scapular spine, located midway between the acromion and the root of the scapular spine. The force is applied transversely and parallel to the long axis of the humerus, with the humerus abducted at 90 degrees [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLower Trapezius\u003c/strong\u003e \u003cp\u003eScapular retraction and depression are the movements of the scapula during LT contraction. Following Hislop et al.\u0026rsquo;s description, the resistance from the HHD is applied to the scapular spine at the midpoint between the acromion and the root of the spine, with the force directed along the upward and lateral direction of the scapular spine, parallel to the long axis of the humerus, and with the humerus at a 140-degree elevation angle [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSerratus Anterior\u003c/strong\u003e \u003cp\u003eScapular abduction is the scapular movement during SA contraction. Following the description by Kendall et al., the participant\u0026rsquo;s elbow is flexed at 90 degrees, and the HHD resistance is applied along the long axis of the humerus to the ulna at the olecranon process [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Due to the inherent instability of this test and the potential involvement of the triceps brachii, the examiner should place the other hand on the participant\u0026rsquo;s triceps to monitor via visual inspection and palpation, ensuring that the triceps does not generate force during the SA muscle test.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"3 Result","content":"\u003cp\u003eAll participants (100%) completed the treatment in this study. There were no significant differences in age, height, weight, FHA, RSD, NDI, VAS scores, and the strength of MT, LT, and SA at baseline between the control group, BE group, and NCBE group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The demographic and general characteristics of the three groups at baseline are \u003cb\u003eshown in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Baseline Characteristics of Participants, Including Age, Height, and Weight\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSig\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e175.67\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e67.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e176.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e66.02\u0026thinsp;\u0026plusmn;\u0026thinsp;7.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e176.53\u0026thinsp;\u0026plusmn;\u0026thinsp;5.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e68.37\u0026thinsp;\u0026plusmn;\u0026thinsp;12.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote\u003c/b\u003e: NCBE: Neuromuscular combined with biomechanical exercise; BE: Biomechanical exercise alone.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eIntra-group Comparisons were conducted using t-tests; the findings are shown in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAt the End of Week 4\u003c/b\u003e: Compared to pre-intervention levels, both the BE and NCBE groups demonstrated significant improvements in all assessment indicators (FHA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RSD: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; NDI: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; VAS Score: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the strength of MT, LT, and SA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, the Control group did not exhibit any significant changes in these measures (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAt the End of Week 8\u003c/b\u003e: When compared to pre-intervention, the BE and NCBE groups continued to show significant improvements in all assessed indicators (FHA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RSD: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; NDI: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; VAS Score: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the strength of MT, LT, and SA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The Control group again showed no significant changes (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cb\u003eComparison Between Week 4 and Week 8\u003c/b\u003e: From the end of Week 4 to the end of Week 8, the BE and NCBE groups experienced further significant improvements in all indicators (FHA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RSD: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; NDI: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; VAS Score: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the strength of MT, LT and SA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant changes were observed in the Control group over this period (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of FHA, RSD, NDI, VAS scores, and the strength of MT, LT, and SA in participants before the intervention, after the 4th week, and 8th week using dependent t-test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre-intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAfter 4th week\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfter 8th week\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFHA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e48.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e48.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e49.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.02\u0026thinsp;\u0026plusmn;\u0026thinsp;2.45a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.46bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e72.63\u0026thinsp;\u0026plusmn;\u0026thinsp;9.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.10\u0026thinsp;\u0026plusmn;\u0026thinsp;8.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.78\u0026thinsp;\u0026plusmn;\u0026thinsp;11.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e72.48\u0026thinsp;\u0026plusmn;\u0026thinsp;9.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.92\u0026thinsp;\u0026plusmn;\u0026thinsp;8.06a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e54.63\u0026thinsp;\u0026plusmn;\u0026thinsp;9.85bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e74.24\u0026thinsp;\u0026plusmn;\u0026thinsp;10.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.92\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e15.66\u0026thinsp;\u0026plusmn;\u0026thinsp;3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.97\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e15.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.34a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e50.47\u0026thinsp;\u0026plusmn;\u0026thinsp;7.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e48.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.47\u0026thinsp;\u0026plusmn;\u0026thinsp;6.61a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e47.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92a*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04a*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.27bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55a*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56bc*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e8.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55a*#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62bc*#\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote\u003c/b\u003e: a: Within-group comparison between Week 4 and Pre-intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); b: Within-group comparison between Week 8 and Pre-intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); c: Within-group comparison between Week 8 and Week 4 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); *: Comparison between the NCBE/BE groups and the Control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); #: Comparison between the NCBE group and the BE group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInter-group Comparisons were conducted using One-way ANOVA and Post-hoc Tukey\u0026rsquo;s test, and these findings are detailed in\u003c/b\u003e Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAt the End of Week 4: One-way ANOVA\u003c/b\u003e revealed significant differences among the groups regarding FHA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), RSD (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), NDI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), VAS Score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the strength of MT, LT, and SA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). \u003cb\u003ePost-hoc Tukey\u0026rsquo;s test\u003c/b\u003e indicated that, at the end of Week 4, the BE and NCBE groups had significantly better outcomes than the Control group in all measured indicators (FHA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RSD: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; NDI: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; VAS Score: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the strength of MT, LT and SA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Notably, the BE and NCBE groups differed significantly only in the strength of the MT, LT, and SA (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no significant differences observed in other indicators (FHA: p\u0026thinsp;=\u0026thinsp;0.371; RSD: p\u0026thinsp;=\u0026thinsp;0.763; NDI: p\u0026thinsp;=\u0026thinsp;0.306; VAS Score: p\u0026thinsp;=\u0026thinsp;0.188).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAt the End of Week 8: The one-way ANOVA\u003c/b\u003e results indicated significant differences among the groups concerning FHA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), RSD (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), NDI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), VAS Score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the strength of MT, LT and SA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). \u003cb\u003ePost-hoc Tukey\u0026rsquo;s test\u003c/b\u003e showed that, at the end of Week 8, the BE and NCBE groups had significantly better outcomes than the Control group in all measured indicators (FHA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RSD: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; NDI: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; VAS Score: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; the strength of MT, LT and SA: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Comparisons between the BE and NCBE groups revealed significant differences in all indicators except for RSD (p\u0026thinsp;=\u0026thinsp;0.116), which included FHA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), NDI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), VAS Score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the strength of the MT (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), LT (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and SA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOne-way ANOVA results were performed for FHA, RSD, NDI, VAS scores, the strength of MT, LT, and SA after 4th week, and after 8th week of different groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSum of Squares\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDegrees of Freedom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFHA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e103.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e201.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e304.412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e619.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e309.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e264.504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e883.790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e873.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e436.686\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2574.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e61.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3447.591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4583.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2285.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3512.722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e83.640\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8096.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e214.270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e107.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e568.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e782.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1115.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e557.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e475.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1591.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1477.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e738.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18.892\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1642.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3119.644\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5237.911\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2618.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e75.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1459.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34.746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6697.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e29.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e243.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e121.550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e89.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e299.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.751\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e27.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.639\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e204.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e102.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e86.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.464\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e253.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e161.439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInter-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e417.561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e208.780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e84.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntra-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e104.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e521.887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cb\u003eNote\u003c/b\u003e: * indicates that the difference in means is statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTukey\u0026rsquo;s test findings to examine the differences between different groups in FHA, RSD, NDI, VAS scores, the strength of MT, LT, and SA after the 4th week, and after 8th week\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup I\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup J\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Difference (I-J)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFHA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.5267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.6133*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.0867\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.7994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.5467*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.9163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.0067*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.9163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.4600*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.9163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.17733*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.85869\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.018*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.18667*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.85869\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.00933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.85869\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.14933*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.33945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.95267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.33945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.80333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.33945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.29267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.34286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.047*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.29267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.34286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.00000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.34286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.39333*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.22905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.86000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.22905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.46667*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.22905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.600*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.667*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.800*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.067*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.54733*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.30707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.29733*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.30707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.75000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.30707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.33667*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.42441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-5.66333*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.42441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.32667*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.42441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.27600*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.29196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.13933*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.29196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.86333*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.29196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.19067*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.39627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-5.16867*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.39627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.97800*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.39627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 4th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.52867*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.55968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.024*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.89133*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.55968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.36267*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.55968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eafter 8th week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.78000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.57550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-7.46133*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.57550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCBE group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.68133*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.57550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cb\u003eNote\u003c/b\u003e: * indicates that the difference in means is statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe external manifestations of UCS include forward head posture, rounded shoulders, and thoracic kyphosis. These issues are primarily attributed to prolonged sedentary behavior, extended periods of desk work, poor lifestyle habits, and excessive exercise. From a biomechanical perspective, muscle strength and length imbalances are likely the primary causes of these problems. From a neuromuscular perspective, insufficient muscle activation may be a key factor.\u003c/p\u003e \u003cp\u003eExtensive research has demonstrated that stretching exercises targeting the levator scapulae, upper trapezius, and other neck extensor muscles, along with the pectoral muscles, and strengthening exercises for the middle and lower trapezius, rhomboids and deep neck flexors, can effectively improve alignment in patients with UCS. For instance, Bae et al. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] implemented a 4-week program of strength and stretching exercises for students with forward head posture; Hajihosseini et al. [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] applied a 6-week stretching and strengthening program for scapular muscles in participants with forward head posture; Hamidiyeh et al. [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] conducted an 8-week stretching and strengthening intervention for participants with thoracic kyphosis; Nitayarak and Charntaraviroj [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] implemented a 4-week strengthening program for UCS patients; Roddey et al. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] applied a 2-week stretching intervention for individuals with forward head posture and rounded shoulders; and Yoo [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] employed a 2-week stretching program for patients with forward head posture. These interventions significantly improved key indicators, including forward head angle, rounded shoulder angle, and kyphotic angle. However, the aforementioned studies primarily focused on biomechanical exercises (strengthening and stretching) and lacked evaluations of neuromuscular exercise interventions for UCS. To achieve optimal correction of UCS, exercise programs should emphasize both biomechanical and neuromuscular factors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, to ensure the effectiveness of the interventions in the experimental groups and based on previous research findings, both the BE and NCBE groups were provided with biomechanical exercises. To address the gaps in prior research (i.e., the lack of studies integrating neuromuscular and biomechanical exercises for UCS) and to differentiate this study from existing research, the NCBE group received a combined neuromuscular and biomechanical exercise program. This design also allowed for a comparison of the effectiveness of NCBE versus BE alone in the intervention for UCS.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIntervention Effects on Outcome Measurements\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003e1. Analysis of Intervention Effects of NCBE and BE on Alignment, NDI, and VAS Scores\u003c/h3\u003e\n\u003cp\u003eAbnormal alignment is an external manifestation of UCS, while neck disability and neck pain represent its internal manifestations. Quantifying the severity of the forward head posture (FHP), rounded shoulders (RS), neck disability (ND), and neck pain (NP) are essential to assess the improvement of UCS. This study used the FHA, NDI, and VAS scores to quantify FHP, ND, and NP, respectively. Additionally, RSD was used to quantify the degree of RS in UCS patients, distinguishing it from traditional rounded shoulder angle measurement methods.\u003c/p\u003e \u003cp\u003eThe results of this study indicate that at the end of weeks 4 and 8 of intervention, both the BE and NCBE groups showed significant improvements in FHP, RS, ND, and NP. The FHP and RSD returned to normal levels (FHA\u0026thinsp;\u0026lt;\u0026thinsp;45\u0026deg;; RSD\u0026thinsp;\u0026lt;\u0026thinsp;5.6 cm).\u003c/p\u003e \u003cp\u003eFrom a biomechanical perspective, the following factors may explain these improvements: First, restoring the length and health of the myofascial tissues reduces the pressure on pain-sensitive structures such as nerves and blood vessels [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This may stimulate the lymphatic system, promote fluid flow, reduce swelling, accelerate recovery, and improve blood circulation to the muscle tissues, facilitating the removal of waste products (e.g., lactic acid) and providing more oxygen and nutrients to the muscles. Second, stretching exercises restore muscles\u0026rsquo; normal length and elasticity, improve joint range of motion, and reduce the pressure on joints from overly tense muscle groups [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Third, strength exercises enhance the strength and endurance of the upper back and deep neck muscles in UCS patients, improving the function of the upper limb diagonal muscles and providing more substantial support for maintaining proper spinal posture. This helps correct abnormal postures like FHP and RS, thereby restoring normal joint alignment [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and relieving NP and ND caused by poor neck posture.\u003c/p\u003e \u003cp\u003eSimilar studies also reported comparable results. Shadi et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] conducted a 6-week NASM-based corrective exercise program for 13\u0026ndash;16-year-old UCS girls, while Abdolahzad et al. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] applied a similar NASM-based correction program for female students. Both studies found significant improvements in FHP, rounded shoulder angle (RSA), and kyphosis, which is consistent with the results of this study. Additionally, Jeong et al. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] applied a Telerehabilitation program combined with diaphragmatic breathing re-education and shoulder stability exercises, which led to significant improvements in FHA, the height of RS, NDI, and upper trapezius pain levels. Mahmood et al. [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] used conventional physical therapy combined with instrument-assisted soft tissue mobilization. Although their intervention methods differ from those used in this study, the underlying principles are similar, i.e., releasing and stretching tense muscles to promote local blood circulation, alleviate muscle swelling and pain, strengthen weak muscle groups, enhance endurance and muscle activation, improve muscle balance, and restore joint alignment.\u003c/p\u003e \u003cp\u003eAdditionally, the results of this study revealed that at the 8-week, the NCBE group showed greater improvement than the BE group in FHA, NDI, and VAS scores, except for the RSD. From a neuromuscular perspective, abnormal alignment can affect the static and dynamic positioning of the scapula, increasing pressure on the cervical spine. NCBE group\u0026rsquo;s posture correction exercises help UCS patients develop healthy postural habits for the cervical, thoracic, and lumbar spine, avoiding FHP, RS, and kyphosis in daily life. Over time, this allows the restoration of normal spinal curvature, reduces abnormal loading on intervertebral discs and surrounding soft tissues, and alleviates pain [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Moreover, previous research has demonstrated that muscle proprioceptive deficits are a potential factor contributing to neck pain, often due to insufficient scapular motor control [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Consciously controlling the scapular muscles may be necessary for improving proprioception and normalizing the resting position of the scapula [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The scapular motor control exercises in NCBE have the following benefits: First, they correct existing scapular dyskinesis in UCS patients, such as excessive anterior tilt or inadequate upward rotation of the scapula, ensuring the scapula follows the correct movement trajectory during daily activities and exercises. Second, electromyography (EMG) data show that scapular orientation exercises (SOE) can effectively increase the activation of muscles such as the middle trapezius (MT) and lower trapezius (LT) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], creating a chain reaction with strength exercises. This results in a more significant increase in the strength of scapular stabilizers, rapidly restoring muscle balance and improving joint alignment. As a result, the NCBE group exhibited superior improvements in alignment, neck disability, and neck pain compared to the BE group.\u003c/p\u003e \u003cp\u003eHowever, by the eighth week, the improvement in RSD was not significantly different between the NCBE and BE groups. This could be because the RSD in the NCBE group had already normalized by the end of the intervention, so the improvement in this measurement diminished over time.\u003c/p\u003e\n\u003ch3\u003e2. Analysis of Intervention Effects of NCBE and BE on Scapular Muscle Strength\u003c/h3\u003e\n\u003cp\u003eUCS patients commonly exhibit weakness and insufficient activation of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA). However, most previous studies primarily focused on measuring outcomes such as joint alignment in the upper back and neck, as well as neck pain, such as forward head angle (FHA), rounded shoulder angle (RSA), neck disability index (NDI), and visual analog scale (VAS), with insufficient evidence regarding the improvement of muscle function. Therefore, to provide a more comprehensive analysis of the effects of UCS interventions, it is crucial to include the study\u0026rsquo;s evaluation of scapular muscle function.\u003c/p\u003e \u003cp\u003eCurrently, two main methods exist for evaluating scapular muscle function: measuring muscle strength or assessing muscle activation levels. Seidi et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] utilized electromyography (EMG) to assess the activation of selected muscles, including the UT, MT, LT, and SA, to measure improved scapular muscle activation following intervention. Lynch et al. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] used handheld dynamometry to assess the strength of scapular muscles to determine the effect of intervention on scapular muscle strength.\u003c/p\u003e \u003cp\u003eStudies have shown that increased scapular muscle strength and activation correlate with alleviating UCS symptoms. Seidi et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] implemented a CCEP exercise program based on a combination of neuromuscular and biomechanical principles. After 8 weeks of intervention, significant increases in the activation of MT, LT, and SA were observed. The results related to alignment (including FHA, RSA, and TKA) and movement patterns (scapular dyskinesis) also showed significant improvement, and the positive effects were maintained even after 4 weeks of discontinuation. Lynch et al. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] conducted an 8-week scapular muscle stretching and strengthening program for participants with FHP and RS. Post-intervention, the participants exhibited significant increases in the strength of the MT, LT and SA, and there were notable improvements in FHA, RSA, neck pain, and neck disability. Nitayarak et al. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] implemented a 4-week scapular stabilization training program for UCS patients, significantly improving scapular muscle strength and effectively alleviating UCS symptoms. The results of this study also indicated that both BE and NCBE interventions led to significant improvements in the strength of the MT, LT, and SA muscles and alleviation of UCS-related symptoms, consistent with previous studies, thereby further confirming the findings of prior research.\u003c/p\u003e \u003cp\u003eHowever, a key difference in this study is that it demonstrated that at both 4 and 8 weeks, NCBE showed a more significant improvement in scapular muscle strength compared to BE alone. From a neuromuscular perspective, we hypothesize that this could be due to the synergistic effect between neuromuscular exercises (postural correction exercises and scapular motor control exercises) and scapular muscle strengthening exercises in the NCBE group. Postural correction exercises and scapular motor control exercises enhance scapular muscle activation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. With increased muscle recruitment, scapular muscle strengthening can maximize the strength improvement of the target muscles, resulting in a more significant effect on muscle strength than BE alone.\u003c/p\u003e \u003cp\u003eNevertheless, this study has certain limitations. The experimental subjects were all male secondary school students aged 15\u0026ndash;18, which slightly limits the sample coverage (excluding all age groups, female or male participants outside the 15\u0026ndash;18 age range). Additionally, although this study used a longitudinal design, the long-term effects of the intervention were not explicitly verified. Therefore, future studies could consider expanding the sample size, including participants from different age groups and both genders, and extending the longitudinal study duration to validate the sustainability of the intervention effects further and enhance the generalizability of the intervention.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eNeuromuscular combined with biomechanical scapular stabilizer exercises have demonstrated significant effectiveness in treating UCS symptoms in secondary school students, particularly in correcting poor alignment, improving neck pain and disability, and enhancing muscle strength. Compared to pure biomechanical exercise, this integrated approach additionally strengthens the development of postural habits, muscle activation, and motor patterns (through neuromuscular exercises), making it more effective in alleviating UCS symptoms. This approach combines the advantages of both factors. Given its safety, cost-effectiveness, ease of implementation, and good adaptability to secondary school students, it shows great potential for widespread application in clinical and school settings. Moreover, the control group in this study also confirmed that treatment of UCS through conventional physical activity alone, without corrective exercise, is ineffective. Overall, this study provides an important approach for preventing and treating UCS in secondary school students and offers valuable directions for future research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors agree to publish this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor Contributions Statement：XMH conceptualized the study, designed the research, conducted the investigation, implemented the clinical trial interventions, measured the clinical trial results, curated the data, and wrote and revised the manuscript (primary contributor).GYB supervised the project, managed the project, and provided resources.XQ performed the clinical trial interventions and measured the clinical trial results.KW approved the final manuscript.All authors reviewed the manuscript.Order of authors\u0026apos; names：XMH is the first author, GYB is the second author, XQ is the third author, and KW is the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMuscolino JE. 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J Man Manipulative Therapy. 2005;13:163\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFirouzjah MH, Firouzjah E, Ebrahimi Z. The effect of a course of selected corrective exercises on posture, scapula-humeral rhythm and performance of adolescent volleyball players with upper cross syndrome. BMC Musculoskelet Disord. 2023;24(1):489.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuivo RM, Pezarat-Correia P, Carita AI. Intrarater and interrater reliability of photographic measurement of upper-body standing posture of adolescents. J Manipulative Physiol Ther. 2015;38(1):74\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung IA et al. Psychometric properties of the Numeric Pain Rating Scale and Neck Disability Index in patients with cervicogenic headache. Cephalalgia, 2019(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim H, et al. 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J Pak Med Assoc. 2021;71(10):2304\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsp\u0026iacute;-L\u0026oacute;pez GV, et al. Efficacy of a proprioceptive exercise program in patients with nonspecific neck pain: a randomized controlled trial. Eur J Phys Rehabil Med. 2021;57(3):397\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLynch SS, et al. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Br J Sports Med. 2010;44(5):376\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Mey K, et al. Kinetic chain influences on upper and lower trapezius muscle activation during eight variations of a scapular retraction exercise in overhead athletes. J Sci Med Sport. 2013;16(1):65\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Upper crossed syndrome, Forward head posture, Round shoulder, Scapular stabilizer muscle corrective exercises, Secondary school students","lastPublishedDoi":"10.21203/rs.3.rs-5789540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5789540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUpper crossed syndrome (UCS), characterized by poor posture, neck pain and Functional disability, is a prevalent issue among youth. This study aims to evaluate the effects of neuromuscular combined with biomechanical exercise (NCBE) on UCS among secondary school students and compares its outcomes with biomechanical exercise (BE) alone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eForty-five male secondary school students (aged 15–18) were divided into three groups: NCBE (n=15), BE (n=15), and a control group (n=15). The NCBE group underwent combined neuromuscular and biomechanical exercise, the BE group performed biomechanical exercise only, and the control group participated in regular physical activities. Interventions were conducted three times a week for eight weeks. Outcome measures, including Forward Head Angle (FHA), Rounded Shoulder Distance (RSD), Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and scapular muscle strength (Middle Trapezius (MT), Lower Trapezius (LT), Serratus Anterior (SA) ), were assessed at baseline, week 4, and week 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin-group comparisons: Both BE and NCBE groups showed significant improvements in all measures by week 4 compared to baseline (p\u0026lt;0.05), with further improvements by week 8 (p\u0026lt;0.05), while the control group showed no significant changes (p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003eBetween the group comparisons: Both BE and NCBE groups had better outcomes than the control group at weeks 4 and 8 (p\u0026lt;0.05). NCBE group showed superior results compared to the BE group only in the strength of MT, LT and SA (p\u0026lt;0.05) in week 4. NCBE group showed superior results compared to BE in FHA, NDI, VAS and the strength of MT, LT and SA (p\u0026lt;0.05), except for RSD (p\u0026gt;0.05) at week 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth NCBE and BE are effective in alleviating UCS symptoms in Chinese secondary school students. However, NCBE demonstrates superior treatment effects compared to BE across multiple outcome measures, offering a promising and cost-effective therapeutic option. Additionally, regular physical activity is ineffective in treating UCS.\u003c/p\u003e","manuscriptTitle":"The Effect of Neuromuscular Combined with Biomechanical Scapular Stabilizer Muscle Corrective Exercises on Upper Crossed Syndrome in Chinese Secondary School Students: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 16:21:05","doi":"10.21203/rs.3.rs-5789540/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb051f9d-e6a4-4451-8315-c3352f110816","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-22T13:23:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-13 16:21:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5789540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5789540","identity":"rs-5789540","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}