The effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children

The effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children | 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 and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children Majid Barzegari, Ali Shamsi Majelan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6330673/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 Purpose: This study aims to compare the effects of posture education and corrective games on the alignment of the thoracic and cervical spine, as well as the daily habits in children. Materials and methods: The statistical population of this study was formed by elementary students with malalignments in the thoracic and cervical spine of Baharestan city (Iran). A total of 60 participants were assigned to this study and using simple and random method with computer-generated random numbers divided into posture education group (PE, n= 20) corrective games group (CG, n= 20) and control group (CON, n= 20) groups. Kyphosis angle, forward head posture and forward shoulder posture measured with a flexible ruler, goniometer, and double square, respectively. Also, daily habits measured with students' daily functional activities questioner. Results: Both the PE and CG showed significant improvements in kyphosis (p = 0.01 for PE, p = 0.02 for CG), forward head posture (p = 0.02 for PE, p = 0.04 for CG), forward shoulder posture (p = 0.001 for PE, p = 0.02 for CG), and daily habits (p = 0.02 for PE, p = 0.03 for CG) after an 8-week training intervention compared to the CON group. However, after a 3-month detraining period, the changes in both the PE and CG were found to be statistically insignificant (p > 0.05). Conclusion: In conclusion, both the EP and CG interventions significantly improved kyphosis, forward head, and shoulder posture, as well as daily activity patterns, without notable differences between them. Additionally, the sustainability of these improvements suggests that participants developed lasting skills and habits that promote ongoing spinal health. Overall, the study reinforces the value of integrating educational and engaging physical activities into curricula to support children's musculoskeletal well-being. Trial Registration IRCT registration number: IRCT20250316065103N1 Registration date: 2025-03-25 (Retrospectively registered) Trial Id: 82539 Posture Education Corrective Games Spine Posture Daily Activities Figures Figure 1 Introductions Good posture serves as a fundamental indicator of both physical and mental well-being, reflecting an optimal equilibrium among the skeletal, muscular, and joint systems [ 1 ]. This balance minimizes undue stress on the body and enhances overall quality of life [ 1 ]. Disruption to this equilibrium can arise from factors such as poor lifestyle choices, environmental influences, and occupational or cultural conditions [ 2 ]. Such disruptions can result in postural abnormalities, leading to consequences like impaired biomechanical balance, muscle fatigue, joint deformities, psychological and social issues, and even neuromuscular pain [ 3 ]. In severe cases, these abnormalities may culminate in permanent and irreversible changes [ 4 ]. Many developmental issues during childhood often emerge when children start school. These problems include back pain and alterations in spinal morphology, which can result from improper body mechanics in daily activities, including the transportation of school supplies, such as backpacks [ 4 ]. Consequently, the body undergoes changes not only due to natural growth but also due to various risk factors that exacerbate pain and related issues. These factors include the use of unsuitable school equipment, inappropriate postures during sitting and lying, and overall physical habits adopted in daily life activities [ 5 , 6 ]. Poor posture in children can result in significant and long-lasting complications [ 6 ]. Numerous studies indicate that inappropriate posture, particularly during growth phases, can adversely affect both the structure and function of the spine [ 7 ]. For instance, poor sitting habits, excessive forward bending, and improper handling of heavy school bags can lead to abnormalities in various spinal regions, especially the thoracic and cervical areas [ 8 ]. Another prevalent consequence of poor posture in children is chronic musculoskeletal pain [ 9 ]. Research demonstrates that prolonged and incorrect sitting, improper use of computers and smartphones, and inadequate carrying techniques for school bags can contribute to persistent pain in the neck, shoulders, and back [ 10 , 11 ]. Consequently, it is crucial to focus on training and correcting physical conditions, particularly during daily activities. Positive or negative alterations in this domain have a direct impact on individuals' physical and mental states, significantly contributing to the prevention of anomalies and the enhancement of overall quality of life [ 12 ]. Preventing physical disabilities in children through school-based interventions is a crucial and effective strategy for enhancing their health and physical performance [ 13 ]. Various interventions have been proposed to improve posture and correct postural abnormalities, with the most significant being posture education and corrective exercises [ 12 ]. Posture education serves as a direct and targeted approach to increase awareness of proper physical alignment, rectify postural issues, and reinforce healthy movement habits [ 14 ]. By raising awareness and educating children on appropriate behaviors and methods for utilizing their bodies and environments—through suitable sports and physical education programs—children can learn essential skills, from sitting correctly to properly carrying bags and using technological devices [ 15 ]. Research indicates that these programs can lead to substantial improvements in children's physical posture [ 16 – 18 ]. Additionally, corrective games represent a novel approach to posture correction. These games have garnered interest from many health professionals due to their interactive and engaging characteristics [ 19 , 20 ]. By incorporating physical exercises into a fun and entertaining format, they motivate children to be more physically active, thereby contributing to improved posture [ 20 ]. In this regard, research suggests that these programs can result in significant enhancements in children's physical posture [ 21 – 23 ]. Previous research has demonstrated that corrective games, due to their engaging and interactive nature, can motivate children to be more physically active, thereby aiding in posture improvement [ 21 – 23 ]. Conversely, posture education focuses directly on enhancing individuals' awareness of correct posture and correcting abnormalities through the teaching of proper techniques [ 16 – 18 ]. While both methods contribute to better posture in students, several ambiguities and questions remain unanswered, such as: Which intervention is more optimal and suitable for improving students' posture and preventing postural abnormalities? Is there a difference in the degree to which these interventions impact students' posture? Which training program is more sustainable? To address these questions, this study aims to compare the effects and durability of posture education and corrective games on the alignment of the thoracic and cervical spine, as well as the daily habits in children. Methods Participants The statistical population of this study was formed by elementary students with malalignments in the thoracic and cervical spine of Baharestan city (Iran). The participants were selected according to the available samples from a province. Participants were required to complete all the training sessions and attend all assessment sessions, and were asked to avoid intense physical activities during the study. As a result of these requirements, a total of 60 participants were assigned to this study and using simple and random method with computer-generated random numbers divided into posture education group (PE, n = 20) corrective games group (CG, n = 20) and control group (CON, n = 20) groups. (Table 1 ). A power analysis was conducted to determine the sufficient sample size of each group. The sample size was calculated based on a previous study by Rajabi, Minoonejad (23) with an alpha level of 0.05, effect size of 0.3 and an actual power (1-beta) of 0.80. The analysis (G × Power, Version 3.1.9.2, University of Kiel, Germany) revealed that a sample size of n = 18 would be sufficient for each group to find significant effects between variables. With the possibility of participants dropping out, the number of participants was considered 10% more for each group. Table 1 Baseline measurements (mean ± SD). Characteristic PE training (n = 20) CG training (n = 20) Control group (n = 20) p-value mean ± SD mean ± SD mean ± SD Age (years) 11.12 ± 1.76 11.76 ± 1.84 11.49 ± 1.39 0.23 Height (cm) 136.21 ± 7.9 135.2 ± 7.89 136.18 ± 6.99 0.11 Body mass (kg) 35.43 ± 4.36 36.23 ± 4.32 35.48 ± 5.12 0.23 BMI (kg/m 2 ) 23.19 ± 2.1 23.46 ± 2.76 23.02 ± 2.86 0.46 *Significance level was considered p ≥ 0.05. BMI: Body mass index; PE: Posture education; CG: Corrective games. The inclusion criteria for the study included: 1) Gender of the participants: male only; 2) Willingness to participants: must express a willingness to take part in the research; 3) Age of participants: should be elementary students (ages 9 to 12); 4) General health: must not have experienced any acute or chronic diseases in the past six months; 5) Parental or legal guardian consent: written consent from a parent or legal guardian is required for participation; 6) No prior participation in similar programs: must not have engaged in similar training or sports programs in the past six months; 7) Spinal status: must be evaluated and approved by a specialist, confirming no significant spinal or neck abnormalities; 8) Ability to attend training sessions: must be capable of attending all training sessions and corrective games; 9) No use of effective medications: should not be taking medications that affect the musculoskeletal system; 10) Absence of psychological issues: must not have psychological problems that could impact their ability to participate in the research. The exclusion criteria for the study were as follows: 1) Regular absence: who miss more than three training sessions or games; 2) Change in health status: who develop acute or chronic diseases during the study period; 3) Failure to comply with instructions: who consistently disobey training guidelines and corrective game protocols; 4) School change: who change schools during the course of the research; 5) Voluntary withdrawal: who choose to discontinue their participation for any reason, with agreement from their parents or guardians. Before the initiation of the study, the participants (children individuals) and their parents were informed about the research procedures, and their written consent was obtained. Table 1 around here Study design This study employed a three-armed cluster-randomized controlled trial design with convenience sampling. The study followed the CONSORT 2010 guidelines for reporting randomized trials [ 24 ]. The participants were pair-matched based on their malalignments and then randomly divided into three groups: posture education group (PE, n = 20) corrective games group (CG, n = 20) and control group (CON, n = 20) groups. The randomization was performed using a computer-generated block randomization table, with a blinded member of the study team responsible for the allocation. The experimental groups participated in their programs, which involved 60-minute sessions, 2 days per week, for a duration of 2 months. The control group performed their regular daily activity. The study period spanned 11 weeks, with the following timeline: Week 1 - Familiarization period; Week 2 - Pre-test period; Weeks 3 to 10 - Training period; Week 11 - Post-test period. In addition, 3 months after post-test (follow-up) the participants were recruited to the school to reassess test results. Two weeks before the training period, a researcher communicated with the participants and standardized the training procedures. The weekly training sessions were co-created between the trainer and the participants, who were instructed to properly execute the prescribed exercises. The study was registered and allocated by the Clinical Trials (IRCT20250316065103N1). Also, the study was approved by the University of Guilan (Iran) IR.GUILAN.REC.1403.169. All experiments were conducted in accordance with the relevant guidelines and regulations. Procedures The participants underwent a total of 2 weeks of testing, which included both pre-tests and post-tests. To minimize the potential impact of circadian variations on the test results, the participants were tested at the exact same time of day (between 8 AM and 11 AM) and on the same day of the week as the pre-test session. Additionally, the testing was conducted during the same training hour as the pre-test, ensuring consistency in the testing conditions at the school. Measurements The participants' height was measured using a wall-mounted stadiometer (Seca 222, Terre Haute, IN) and recorded to the nearest 0.5 cm. Their body mass was measured to the nearest 0.1 kg using a digital scale (Tanita, BC-418MA, Tokyo, Japan) [ 25 ]. Kyphosis measurement: A flexible ruler was employed to measure the dorsal curvature of the spine due to its characteristics of being inexpensive, non-invasive, and quick. Participants were asked to uncover their upper bodies, allowing the researcher to observe and palpate the spine to identify the second and twelfth dorsal vertebrae. To locate the second dorsal vertebra, the participant was instructed to bend their head forward while standing. In this position, the researcher identified the most prominent vertebra, the seventh cervical vertebra, by touch. From there, two vertebrae below the seventh cervical vertebra were marked as the second dorsal vertebra. For the twelfth dorsal vertebra, the participant placed their hands on the edge of a table and shifted their weight forward into a semi-bent position. The researcher identified the twelfth vertebra by palpating the twelfth rib on both sides, following the rib's path upward and inward until it disappeared into the soft tissue. If there was uncertainty regarding the location of the twelfth vertebra, the subject was asked to bend forward while the researcher placed their thumbs at the suspected location. The movement felt during bending and extension confirmed the exact position of the twelfth vertebra, as it is adjacent to the junction of the thoracic and lumbar vertebrae, with the first lumbar vertebra located just below it. Once the points were identified, they were marked with an easily erasable marker. All measurements were taken while the participants stood in a relaxed position, distributing their weight evenly between both feet and looking straight ahead. After marking the points, the flexible ruler was placed along the spine, conforming to its shape without any gaps. The marked points were then transferred to the ruler. The ruler was carefully removed, and the curvature was drawn on paper with a pencil, marking the identified points on the drawn curvature. The distance between the two points (L) and the deep of the curvature (H) were measured using the ruler. These measurements were inserted into the formula \(\:{\theta\:}=4\text{A}\text{r}\text{c}\text{tan}2H/L\) to calculate the kyphosis angle [ 26 ]. Forward head measurement; to measure the forward head angle using a goniometer, specific anatomical points were identified, including the tragus of the ear, the spinous process of the C7 vertebra, and the acromion prominence, which serve as reference points for assessing the position of the head and shoulders. The participant was placed in a natural standing position and instructed to focus their gaze on a point along the horizon. The goniometer was then positioned with its center at the tragus of the ear, one arm aligned parallel to an imaginary line drawn from the tragus to the C7 vertebra, and the other arm aligned with a horizontal line parallel to the ground. The angle obtained from this setup was recorded as the forward head angle. To minimize human error, each measurement was repeated three times, and the average value was calculated as the final data point. This method is widely used in corrective movement studies and postural analysis due to its simplicity, accuracy, and effectiveness in evaluating posture [ 27 ]. Measuring the forward shoulder posture using the "double square" tool: the device utilized for measuring the forward shoulder position consists of a 40 cm composite ruler attached inverted to an additional surface, allowing for precise measurement of the distance from the anterior tip of the acromion to the wall. Studies have demonstrated that this method exhibits very high interrater reliability (ICC = 0.99 and SEM = 0.1 mm), underscoring the tool's accuracy and efficiency in assessing forward shoulder position [ 28 ]. The location of the anterior tip of the acromion on both the right and left shoulders of the participate was marked by touch and with a permanent marker. participates placed their heels against a wall and were instructed to maintain a "military stance" to ensure stability and prevent changes in body position. The double square tool was positioned so that one square was tangent to the wall. The second square was gently adjusted to contact the anterior tip of the acromion. The distance between the wall and the acromion tip was recorded to the nearest millimeter. This measurement was repeated three times for each shoulder, and the average was recorded for statistical analysis. After recording values in the military position, the participate returned to a natural and relaxed position, and the measurement process was repeated. To achieve the military position, participates were instructed to: Stand straight with shoulders pulled back and chest opened. Tuck the chin in slightly and keep the head straight. Place feet firmly on the floor while keeping the knees in a natural position. In this stance, participates were encouraged to maintain natural body balance without excessive muscle tension or unnatural bending. The military position serves as a standard reference for comparing the subject's natural position and helps prevent unwanted changes in body posture during the test [ 29 ]. daily habits measurement: to assess students' daily functional activities, a researcher-developed questionnaire based on the study of Emami, Shamsi Majelan and Norasteh (18) was utilized. The reliability of the questionnaire was evaluated using the Cronbach's alpha method, which yielded a reliability coefficient of 0.82, indicating a high level of internal consistency. Validity was confirmed by teachers and experts in corrective movements, ensuring that the content accurately reflects the intended measurements of daily activities. The questionnaire comprised 19 questions organized into three dimensions, with each dimension containing a specific number of questions related to daily functioning. Additionally, several questions included visual aids to enhance understanding and engagement. Scores ranged from 0 to 19, with scores closer to 0 indicating poorer performance in daily activities, while scores closer to 19 reflected better performance. This structured approach provides valuable insights into the students' daily lives, facilitating targeted interventions to improve their overall well-being [ 18 ]. Interventions Postural education program The training sessions incorporated in the current study are designed to address postural disorders, particularly among mothers and students, drawing from established "back school" programs prevalent in existing research. These health education initiatives aim to mitigate injuries and enhance the quality of life for individuals suffering from chronic musculoskeletal pain, notably spinal discomfort, by promoting appropriate activities of daily living. The program implemented in this study mirrors these objectives but is tailored to the audience: parents and guardians received educational materials over two sessions, while students were taught using simplified language for better comprehension [ 30 – 32 ]. The content of the training is structured into several key modules. The first module, "Anatomy of the Human Body," covers the structure and function of various body parts, including bones, joints, and the spine, supplemented by illustrative slides. The second module focuses on "Movement, Posture, Balance, and Body Awareness," emphasizing concepts such as the center of gravity and its relation to posture and movement, as well as static and dynamic balance [ 30 – 32 ]. The third module addresses "Sitting," where participants analyze sitting positions in both classroom and home environments. This includes distinguishing between comfortable and correct sitting and exploring various sitting types, such as on the floor, at a desk, or in a chair. Practical exercises were conducted, where one student demonstrated different sitting positions while peers analyzed spinal alignment. Additionally, ergonomic solutions for computer desk setups were presented to mothers, encouraging students to optimize their workstations through simple adjustments, such as elevating the monitor or using a shoebox as a footrest [ 30 – 32 ]. The fourth module, "Picking Up, Putting On, and Carrying a Backpack," involved a hands-on analysis of commonly used items. Students practiced moving objects while the researcher monitored their techniques to prevent harmful movements. Discussions included the weight, size, and shape of backpacks, with individual assessments to adjust strap sizes and materials for optimal fit. Emphasis was placed on weight management, advising students on the organization of backpack contents—placing heavier items closer to the body—and demonstrating the correct lifting technique by recommending that backpacks be placed on elevated surfaces before being worn. To reinforce learning, students practiced various carrying styles, while peers provided feedback on their posture and technique [ 30 – 32 ]. Corrective games program Table 2 summarizes the protocol for a series of corrective games designed to enhance physical fitness and postural alignment among participants. Each game focuses on specific muscle groups and includes details about objectives, participants, equipment, and variations for progressive difficulty. This structured approach not only fosters physical development but also encourages teamwork and awareness of posture, ultimately contributing to improved musculoskeletal health [ 21 ] (Table 2 ). Table 2 Summarizes the protocol for a series of corrective games Game Title Objective Number of Participants Playing Area Required Equipment Game Description Variations/Progression Snake Crawling Forward - Tent on the Ball Stretching the large back, large chest, and small muscles 2 groups of 10 20 × 10 Swiss balls (size 45 or 55) Participants are divided into two groups. They start 20 meters apart, kneel, and place their forearms on the ball while maintaining a natural head and neck position. Subsequent participants pass over their partner to take position. The last member calls for movement, and the first group to cover the distance wins. The game is played in 2 rounds. - Weeks 1–2: 12-meter track length; walking/running - Weeks 3–4: 16-meter track with two 30-cm obstacles - Weeks 5–6: 18-meter track with three 30-cm obstacles - Weeks 7–8: 16-meter track with lunges maintaining correct posture Carrying a Book (Bag...) with the Head Stretching the pectoralis major/minor and internal rotators of the shoulder 2 groups of 10 20 × 10 One-meter-long stick, a book or object Participants place a stick on their back and a book on their head. They move back and forth, passing the book to the next player. Each drop costs a point. The group that finishes faster with fewer errors wins. The game is played in 2 rounds. - Weeks 1–2: 12-meter track length - Weeks 3–4: 16-meter track with obstacles - Weeks 5–6: 18-meter track with more obstacles - Weeks 7–8: Emphasis on correct form Passing the Ball Under the Bridge Stretching the pectoralis major/minor, internal rotators of the shoulder 2 groups of 10 20 × 10 Volleyball or training ball (35 cm diameter) Participants assume a crab position and pass the ball under their bodies to teammates. The last person moves to the front after catching the ball. The team that reaches the end first wins. - Weeks 1–2: 12-meter path - Weeks 3–4: 16-meter path with obstacles - Weeks 5–6: 18-meter path with increased obstacles - Weeks 7–8: Focus on maintaining form Catapult - Middle Strengthening the parallelogram muscles, middle/lower trapezius, external rotators 2–16 20 × 10 Spiked exercise ball (45 cm), exercise band (1-1.2 m) One group holds an exercise ball with bands while the other group throws balls at them. Points are deducted for hits. The game is played in three sets, with each player throwing three times before switching groups. The group with the fewest hits wins. - Weeks 1–4: Elbows flexed - Weeks 5–8: Elbows opened for better hold on the ball Cable Car - Crossing the River Strengthening the parallelogram and trapezius muscles 1–16 20 × 10 Two ropes (15 m long) Two ropes are fixed at a height. Participants hook an elastic to the rope and pull themselves along it, ensuring shoulders and head touch the ground before moving on. The first team to finish wins. - Weeks 1–2: 6-meter path - Weeks 3–4: 7-meter path - Weeks 5–8: 8-meter path Ant (Carrying Luggage) Strengthening deep flexor muscles of the neck 2–16 20 × 10 Book or bag, exercise elastic (yellow and red) Participants balance a book or bag on their heads while pulling an elastic band. They pass the item to teammates at the end of the path. The first team to finish wins, with penalties for drops. - Weeks 1–2: Use yellow elastic, walk/run - Weeks 3–4: Navigate over obstacles - Weeks 5–6: More obstacles - Weeks 7–8: Use red elastic with obstacles Table 2 around here Statistical analysis All values are presented as mean ± standard deviation (SD). The pre- and post-values for the dependent variables were analyzed to determine if the distributions were normal using the Shapiro-Wilk Normality test. Differences in all variables were analyzed using a 3 (group) x 3 (time) repeated measures ANOVA. When a significant F-value was achieved across time or groups, Bonferroni post-hoc procedures were performed to identify the specific pairwise differences. Additionally, the effects of training (effect size [ESs]) were calculated using Cohen's d [ 33 ]. Results In the primary stage of the study, 68 male children recruited in the study and then based on inclusion and exclusion criteria 60 participants were included and allocated into 3 groups (n = 20 for each group). To be included in the final analyses, participants were required to complete all the training sessions and attend all assessment sessions. As a result of these requirements, no participants were excluded from the study. This indicates that all individuals who met the criteria were able to participate fully. Therefore, 20 participants for each group were included for final analysis (Flowchart). Flowchart around here Before training, no significant differences were observed for dependent variables in groups (p > 0.05). No significant changes in the CON were observed in all variables after training period (p > 0.05). The test-retest reliability coefficient of these tests was r ≥ 0.89. To assess intraclass correlation coefficient (ICC), two measurements were made with 48 h apart and the ICC for the tests was r ≥ 0.89. There was a significant interaction between group and time for kyphosis (F = 5.2, p = 0.01), forward head posture (F = 4.2, p = 0.02), forward shoulder posture (F = 3.9, p = 0.001), and daily habits (F = 6.1, p = 0.001). Both the PE and CG showed significant improvements in kyphosis (p = 0.01 for PE, p = 0.02 for CG), forward head posture (p = 0.02 for PE, p = 0.04 for CG), forward shoulder posture (p = 0.001 for PE, p = 0.02 for CG), and daily habits (p = 0.02 for PE, p = 0.03 for CG) after an 8-week training intervention compared to the CON group. However, after a 3-month detraining period, the changes in both the PE and CG were found to be statistically insignificant. The p-values for kyphosis (PE = 0.23, CG = 0.33), forward head posture (PE = 0.56, CG = 0.36), forward shoulder posture (PE = 0.36, CG = 0.43), and daily habits (PE = 0.23, CG = 0.16) indicate that these differences were not significant (Table 3 ). Table 3 Significant and effect size for the variables in the groups [n = 60]. Variables Groups Time point values (mean ± SD) Statistic Effect size (95% CI) and p-Value Pre Post 3-month post Pre to post ES p-value Post to 3-month post ES p-value Kyphosis PE 35.14 ± 5.19 28.35 ± 6.14* 29.17 ± 5.34 G = 0.02 1.12 (0.37 to 1.86) d 0.001 -0.14 (-0.46 to -0.23) a 0.34 CG 34.79 ± 5.67 28.11 ± 5.76* 29.11 ± 6.11† T = 0.01 1.21 (0.48 to 1.79) d 0.003 -0.19 (-0.56 to -0.28) a 0.29 CON 36.19 ± 5.37 35.76 ± 5.85 36.41 ± 5.11 G×T = 0.01 - - Forward head PE 36.44 ± 4.28 30.17 ± 5.47* 30.43 ± 5.47 G = 0.03 1.48 (0.36 to 1.86) d 0.002 -0.21 (-1.08 to -0.68) b 0.49 CG 35.86 ± 5.12 30.11 ± 5.6* 31.11 ± 4.61 T = 0.03 1.26 (0.26 to 1.56) d 0.001 -0.24 (-1.14 to -0.62) b 0.26 CON 34.98 ± 5.11 35.12 ± 4.97 35.16 ± 5.29 G×T = 0.02 - - Forward shoulder PE 16.43 ± 4.48 11.76 ± 4.12* 11.49 ± 4.46 G = 0.02 1.39 (0.14 to 1.54) d 0.001 -0.23 (-0.98 to -0.77) a 0.46 CG 16.11 ± 5.12 10.35 ± 4.43* 11.16 ± 5.18 T = 0.02 1.42 (0.16 to 1.63) d 0.002 -0.43 (-1.12 to -0.64) b 0.36 CON 15.98 ± 4.98 16.47 ± 4.36 16.49 ± 4.79 G×T = 0.001 - - Pattern of daily activities PE 9.11 ± 5.16 14.26 ± 4.19* 13.14 ± 5.72 G = 0.01 0.98 (0.38 to 1.4) d 0.001 -0.24 (-1.11 to 0.86) a 0.31 CG 9.76 ± 5.19 15.06 ± 5.43* 14.43 ± 5.26 T = 0.001 1.01 (0.66 to 1.78) d 0.001 -0.21 (-1.1 to 0.89) a 0.28 CON 10.11 ± 5.18 11.08 ± 4.98 10.87 ± 5.18 G×T = 0.001 - - PE: Posture education; CG: Corrective games., CON; control; G: group; T: time; CI: confidence interval; a: trivial; b: small; c: moderate; d: large ES. *Significant differences compared to pre and CON (p < 0.05), † significant differences compared to post (p < 0.05). Table 3 around here Discussion This study was designed to examine the effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children. The findings of this study indicated that both EP and CG groups decreased kyphosis angle, forward head posture, forward shoulder posture and improved daily habits of children. Also, results indicated that following the 3-month follow period no significant changes were observed in the measured variables.These findings are in line with results of previous studies [ 15 , 21 – 23 , 34 ] which examined the effects of EP or CG on spine posture and found significant effects. In explaining the impact of the EP on children's spines, it can be stated that this initiative functions as a targeted educational intervention designed to enhance awareness of proper body mechanics and postural alignment [ 14 ]. This educational framework focuses on increasing awareness regarding optimal postural alignment, rectifying postural deviations, and promoting sustainable movement patterns [ 35 ]. By fostering awareness of correct posture, the program aims to mitigate the risk of developing postural deformities such as kyphosis, forward shoulder posture, and forward head posture [ 14 ]. It emphasizes the importance of educating students about appropriate postural behaviors and the biomechanical principles governing body use in various environments [ 36 ]. Instruction encompasses a wide range of activities, from proper sitting techniques to ergonomic practices for carrying loads and utilizing technological devices. Integrated into physical education curricula, the EP utilizes sports and physical activities to reinforce correct movement habits [ 37 ]. Through this comprehensive approach, the program effectively equips children with the knowledge and skills necessary to maintain proper posture, thereby reducing the likelihood of spinal deformities and promoting overall musculoskeletal health. Additionally, in discussing the effect of the CG on children's spines, it can be noted that the training regimen for the corrective games group comprised a variety of movements, including activities such as "wooden houses," "trying to get up," "airplanes," and "mice and cats," all designed to elongate shortened muscles [ 19 ]. Additionally, exercises such as "carrying a tennis ball," "judging a blackboard," "pull-pull," "broken knee," and "trying to get up" were employed to enhance muscle strength [ 21 ]. These movements significantly contributed to the improvement of spinal posture complications [ 19 ]. A key mechanism behind the effectiveness of corrective games lies in their engaging nature and the collaborative group dynamics, which serve to motivate participants to engage in the exercises [ 22 ]. Corrective games represent a more accessible and effective approach for enhancing spinal posture. Their inherent motivational aspects, stemming from their enjoyable nature, make them particularly suitable for children, aiding in the correction of maladaptive spinal postures [ 20 ]. Regarding the long-term sustainability of both programs, it can be stated that the focus is on correcting body alignment, strengthening the supporting muscles, and enhancing shoulder stability, while also emphasizing the importance of proper movement patterns [ 38 ]. These elements are crucial as they contribute to an increased awareness of body posture in a corrected and controlled manner, facilitated by the nervous system [ 23 ]. By fostering this awareness, the programs promote lasting effects on spinal health and overall musculoskeletal function [ 39 ]. The integration of these principles ensures that participants not only achieve immediate improvements but also develop the necessary skills and habits to maintain these benefits over time, ultimately supporting sustained spinal alignment and stability [ 38 ]. Furthermore, the results of the study indicated that both the EP and CG exhibited improvements in the daily habits, with no notable difference in the effectiveness of each program in enhancing daily habits. These findings align with previous studies [ 17 , 34 , 40 , 41 ], which investigated the effects of EP and CG on daily activity patterns and reported significant positive outcomes. This consistency in results suggests that both programs are effective in promoting healthier daily behaviors. The effective application of body mechanics, as demonstrated in EP and CG classes, enhances the musculoskeletal system's adjustments by improving balance and distributing the effort needed for daily activities, which can help alleviate pain and slow degenerative processes [ 41 ]. However, this relief relies on the intricate interactions between biomechanical and neuromuscular functions. Changing habits is challenging, as postural habits are deeply ingrained in both movement patterns and mental frameworks [ 34 ]. Interventions aimed at altering poor postural habits must create opportunities for reflection and understanding of the associated postures and movements. It's also crucial to consider the psychological and cultural factors that influence the formation of postural habits [ 41 ]. For a habit to change, individuals need to learn to observe and interpret the sensations produced by their movements, which is the goal of EP and CG interventions [ 42 ]. The EP methodology encourages greater autonomy for individuals in addressing posture-related issues in their daily lives [ 41 ]. The educational activities highlighted in this study are designed to promote proper postures through habit modification, serving as a vital approach to health promotion [ 42 ]. These programs should be tailored to address lifestyles and behaviors that contribute to or exacerbate health problems, allowing for individual modification. Another significant aspect addressed in this study is the examination of the impact of time on the retention of knowledge and habits acquired following the intervention. Consistent with previous research [ 43 , 44 ], our findings demonstrate that improvements in knowledge and habits were maintained compared to pre-test levels. Although our follow-up assessment occurred three months post-intervention, studies with extended follow-up durations—ranging from one year [ 45 , 46 ] to eight years [ 47 ]—have also reported comparable results. This sustained improvement over time suggests a positive long-term effect of interventions on both knowledge and habits. Limitations and future scope This study has several methodological limitations that deserve attention. Firstly, the findings are specific to male children aged 9–12, highlighting the need for further research to determine if these results can be generalized to female children across different age groups. Additionally, while the use of a questionnaire to assess daily activities is valuable for systematically capturing subjective perceptions due to its ease of use and low cost, it may introduce bias. This bias arises because responses are heavily influenced by the participants' perceptions and cognitive abilities. Furthermore, questionnaires cannot verify how well individuals incorporate theoretical knowledge into practice or how this knowledge translates into movement, which could be assessed more effectively through video analysis of dynamic posture. Conclusion In conclusion, both the EP and CG interventions resulted in significant reductions in kyphosis angle, forward head posture, forward shoulder posture while also enhancing daily activity patterns without notable differences in effectiveness between the two programs. The findings highlight the importance of fostering awareness of proper body mechanics and postural alignment, which are essential for preventing postural deformities. Additionally, the sustainability of these improvements suggests that participants developed lasting skills and habits that promote ongoing spinal health. Overall, the study reinforces the value of integrating educational and engaging physical activities into curricula to support children's musculoskeletal well-being. Abbreviations PE Posture education CG Corrective games Declarations Ethical Considerations Compliance with ethical guidelines The study was approved by the University of Guilan (Iran) IR.GUILAN.REC.1403.169. All experiments were conducted in accordance with the relevant guidelines and regulations. Human Ethics and Consent to Participate declarations This study has used the principles of the Declaration of Helsinki, the general guide to ethics in research with human subjects, and its governing regulations. Before the initiation of the study, the participants (children individuals) and their parents or legal guardians were informed about the research procedures, and their written consent was obtained. Informed consent All participants were informed of the purpose and procedure of this study, and informed consent was obtained from all participants. Consent for publication Not Applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors have no conflicts of interest to declare. Funding This research received no funding from any agency in the public, commercial, or not-for-profit sector. Author contributions M.B. & A.SHM.: data acquisition and analysis. M.B. & A.SHM.: data interpretation. M.B. & A.SHM.: wrote the main manuscript text and prepared the figures. M.B. & A.SHM.: conception/design of the work. M.B. & A.SHM.: reviewed and contributed to the manuscript. Acknowledgments The researcher would like to express gratitude towards all the participants that contributed to conducting the study. References Sharma S, Rawat V. 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Mitova S, Popova D, Gramatikova M. Postural disorders and spinal deformities in children at primary school age. System for screening, examination, prevention and treatment. Activities Phys Educ sport. 2014;4(2):172–7. Valenciano PJ, Cibinello FU, Neves JCJ, Fujisawa DS. Effects of postural education in elementary school children: a systematic review. Revista Paulista de Pediatria. 2020;39:e2020005. Santos NBd, Sedrez JA, Candotti CT, Vieira A. Immediate and follow-up effects of a posture education program for elementary school students. Revista Paulista de Pediatria. 2017;35:199–206. Sánchez-Matas Y, Gutiérrez D, Salido López JV, Hernández Martínez A. Design and validation of instruments for assessing sitting posture and fine motor function in primary school students. MHSalud. 2022;19(1):112–29. Maria G-PA, Josep V-C. Effects of postural education on daily habits in children. Intervention effects from the PEPE study; 2022. Emami S, Shamsi Majelan A, Norasteh AA. The Effect of a daily activity pattern education program on parent and teacher's awareness and student’s spine. Stud Sport Med. 2023;15(36):39–56. Ahmadnezhad L, Ebrahimi Atri A, Khoshraftar Yazdi N, Sokhangoei Y. The effect of eight-weeks corrective games on kyphosis angle and postural control in mentally retarded children having kyphosis. J Res Health. 2015;5(2):178–83. Ahmadnezhad L, Ebrahimi-Atri A, Khoshraftar-Yazdi N, Sokhangoei Y. Effect of eight weeks corrective games on kyphosis curve and strengths of trunk muscle in kyphotic mentally retarded children. Archives Rehabilitation. 2016;17(2):178–87. Salamat H, Ghani Zadeh Hesar N, Roshani S, Mohammad Ali Nasasb Firouzjah E. Comparison of the Effect of Functional Corrective Exercises and Corrective Games on Upper Cross Syndrome in 10–13 Year-Old Boys. Sci J Rehabilitation Med. 2020;9(4):19–31. Daneshjoo A, Mousavi Sadati SK, Pourahmad F. Effect of corrective exercise vs corrective games on upper crossed syndrome in female students. Phys Treatments-Specific Phys Therapy J. 2021;11(1):13–24. Rajabi F, Minoonejad H, Seidi F, Rajabi R. To Compare the Effect and Sustainability of a Course Corrective Games with Selected‎ Corrective Exercise on 10–12 Aged Boys with Hyper Thoracic Kyphosis. J Paramedical Sci Rehabilitation. 2022;11(3):29–41. Schulz KF, Altman DG, Moher D, Group* C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726–32. Tipton PH, Aigner MJ, Finto D, Haislet JA, Pehl L, Sanford P, Williams M. Consider the accuracy of height and weight measurements. Nursing2023. 2012;42(5):50–2. Torres-Cusihuaman L, Bravo-Cucci S. Association between thoracic kyphosis and forward head posture in teenagers: an analytical cross-sectional study. Middle East J Rehabilitation Health Stud. 2023;10(4). Gray K, Dalal R, Weaver JD, Randolph S. Quantitative measurements of forward head in college-aged students: a conformational study of intra-rater and inter-rater reliability of a novel posture measuring device. J Bodyw Mov Ther. 2021;26:233–7. Kluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. J sport rehabilitation. 2006;15(1):58. Carvalho LA, Aquino CF, Souza TR, Anjos MTS, Lima DB, Fonseca ST. Clinical measures related to forward shoulder posture: a reliability and correlational study. J Manip Physiol Ther. 2019;42(2):141–7. Minghelli B, Nunes C, Oliveira R. Back School Postural Education Program: Comparison of Two Types of Interventions in Improving Ergonomic Knowledge about Postures and Reducing Low Back Pain in Adolescents. Int J Environ Res Public Health. 2021;18(9). Bartz PT, Vieira A, Noll M, Candotti CT. Effectiveness of the back school program for the performance of activities of daily living in users of a basic health unit in Porto Alegre, Brazil. J Phys Ther Sci. 2016;28(9):2581–6. Minghelli B, Nunes C, Oliveira R. Effectiveness of a Back School and Postural Education Program on the improvement of literacy about postures and low back pain in adolescents: A 1-year follow-up study. J Orthop Sci. 2021;26(4):543–7. Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863. Miñana-Signes V, Monfort-Pañego M, Rosaleny-Maiques S. Improvement of knowledge and postural habits after an educational intervention program in school students. 2019. Araújo CL, Moreira A, Carvalho GS. Postural education programmes with school children: A scoping review. Sustainability. 2023;15(13):10422. Bettany-Saltikov J, McSherry R, Van Schaik P, Kandasamy G, Hogg J, Whittaker V, et al. PROTOCOL: School‐based education programmes for improving knowledge of back health, ergonomics and postural behaviour of school children aged 4–18: A systematic review. Campbell Syst Reviews. 2019;15(1–2):e1014. Mandzáková M, Slováková M. The Intervention Program effect on the Quality of Children’s Body Posture at Elementary Education Level. Sport Mont. 2023;21(3):57–63. Sheikhhoseini R, Kamelan M. Child-centered Corrective Exercises: A Multidisciplinary Approach to Posture Improvement in Children. J Pediatr Rev. 2025;13(1):1–4. Grygus I, Nesterchuk N, Hrytseniuk R, Rabcheniuk S, Zukow W. Correction of posture disorders with sport and ballroom dancing. Медичні перспективи. 2020;25(1):174–84. Vidal J, Borras P, Ortega F, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32(04):303–8. Galmes-Panades AM, Vidal-Conti J, editors. Effects of postural education program (PEPE Study) on daily habits in children. Frontiers in Education; 2022: Frontiers Media SA. Desouzart G, Filgueiras E. PostureMind—Postural Education in Back Pain and Postural Habits of Children and Teenagers. Occupational and Environmental Safety and Health. Springer; 2023. pp. 31–41. Geldhof E, Cardon G, De Bourdeaudhuij I, Danneels L, Coorevits P, Vanderstraeten G, De Clercq D. Effects of back posture education on elementary schoolchildren’s back function. Eur Spine J. 2007;16:829–39. Vidal J, Borras PA, Ponseti FJ, Cantallops J, Ortega FB, Palou P. Effects of a postural education program on school backpack habits related to low back pain in children. Eur Spine J. 2013;22:782–7. Méndez FJ, Gómez-Conesa A. Postural hygiene program to prevent low back pain. Spine. 2001;26(11):1280–6. Geldhof E, Cardon G, De Bourdeaudhuij I, De Clercq D. Back posture education in elementary schoolchildren: a 2-year follow-up study. Eur Spine J. 2007;16:841–50. Dolphens M, Cagnie B, Danneels L, De Clercq D, De Bourdeaudhuij I, Cardon G. Long-term effectiveness of a back education programme in elementary schoolchildren: an 8-year follow-up study. Eur Spine J. 2011;20:2134–42. Additional Declarations No competing interests reported. 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-6330673","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":441071401,"identity":"ca2727c2-4ec3-462b-b566-b9f4b106ce55","order_by":0,"name":"Majid Barzegari","email":"","orcid":"","institution":"University of Guilan","correspondingAuthor":false,"prefix":"","firstName":"Majid","middleName":"","lastName":"Barzegari","suffix":""},{"id":441071402,"identity":"56fe7506-1f75-4711-b7ce-9d3dfbb0e992","order_by":1,"name":"Ali Shamsi Majelan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCRBhYMPAwMzcABFhJk5LGlAlI0laGA4DMUwLISA/u/npxh8F5+02HGds/FzAYCfPwM77AK8WgzvHzG7zGNxO3nCYsVl6BkOyYQMzuwF+LRIJZrcZgFoMDjM2SPMwMCcwMLMRcNiM9G83fxicA2lp/s3DUE9YC8ONHLMbPAYH7IBa2oC2HCasxeBGThnQL8kJkkAt1jwGxw3biHDYtps//tjZ850/fPg2T0W1PD//MQIOg4LEBoilDAyEfAIH9sQqHAWjYBSMghEIAIHGPPUzt9eoAAAAAElFTkSuQmCC","orcid":"","institution":"University of Guilan","correspondingAuthor":true,"prefix":"","firstName":"Ali","middleName":"Shamsi","lastName":"Majelan","suffix":""}],"badges":[],"createdAt":"2025-03-28 20:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6330673/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6330673/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80712767,"identity":"b534ab01-4055-4cb0-b247-452366405e5c","added_by":"auto","created_at":"2025-04-16 09:19:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84282,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart. \u003c/strong\u003eFlowchart of eligibility, inclusion and exclusion criteria, and analysis. CG: corrective games; PE: posture education\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6330673/v1/e5792a7b3c4528ba2fe8fc75.png"},{"id":87022264,"identity":"80b3230f-f457-4b55-810c-834c9113da7d","added_by":"auto","created_at":"2025-07-18 11:24:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1254833,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6330673/v1/abef6b0f-cca0-4ac5-88d3-7b2210470198.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children","fulltext":[{"header":"Introductions","content":"\u003cp\u003eGood posture serves as a fundamental indicator of both physical and mental well-being, reflecting an optimal equilibrium among the skeletal, muscular, and joint systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This balance minimizes undue stress on the body and enhances overall quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Disruption to this equilibrium can arise from factors such as poor lifestyle choices, environmental influences, and occupational or cultural conditions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Such disruptions can result in postural abnormalities, leading to consequences like impaired biomechanical balance, muscle fatigue, joint deformities, psychological and social issues, and even neuromuscular pain [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In severe cases, these abnormalities may culminate in permanent and irreversible changes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany developmental issues during childhood often emerge when children start school. These problems include back pain and alterations in spinal morphology, which can result from improper body mechanics in daily activities, including the transportation of school supplies, such as backpacks [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, the body undergoes changes not only due to natural growth but also due to various risk factors that exacerbate pain and related issues. These factors include the use of unsuitable school equipment, inappropriate postures during sitting and lying, and overall physical habits adopted in daily life activities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePoor posture in children can result in significant and long-lasting complications [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Numerous studies indicate that inappropriate posture, particularly during growth phases, can adversely affect both the structure and function of the spine [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For instance, poor sitting habits, excessive forward bending, and improper handling of heavy school bags can lead to abnormalities in various spinal regions, especially the thoracic and cervical areas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another prevalent consequence of poor posture in children is chronic musculoskeletal pain [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Research demonstrates that prolonged and incorrect sitting, improper use of computers and smartphones, and inadequate carrying techniques for school bags can contribute to persistent pain in the neck, shoulders, and back [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsequently, it is crucial to focus on training and correcting physical conditions, particularly during daily activities. Positive or negative alterations in this domain have a direct impact on individuals' physical and mental states, significantly contributing to the prevention of anomalies and the enhancement of overall quality of life [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreventing physical disabilities in children through school-based interventions is a crucial and effective strategy for enhancing their health and physical performance [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Various interventions have been proposed to improve posture and correct postural abnormalities, with the most significant being posture education and corrective exercises [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Posture education serves as a direct and targeted approach to increase awareness of proper physical alignment, rectify postural issues, and reinforce healthy movement habits [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By raising awareness and educating children on appropriate behaviors and methods for utilizing their bodies and environments\u0026mdash;through suitable sports and physical education programs\u0026mdash;children can learn essential skills, from sitting correctly to properly carrying bags and using technological devices [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Research indicates that these programs can lead to substantial improvements in children's physical posture [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, corrective games represent a novel approach to posture correction. These games have garnered interest from many health professionals due to their interactive and engaging characteristics [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. By incorporating physical exercises into a fun and entertaining format, they motivate children to be more physically active, thereby contributing to improved posture [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In this regard, research suggests that these programs can result in significant enhancements in children's physical posture [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research has demonstrated that corrective games, due to their engaging and interactive nature, can motivate children to be more physically active, thereby aiding in posture improvement [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Conversely, posture education focuses directly on enhancing individuals' awareness of correct posture and correcting abnormalities through the teaching of proper techniques [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While both methods contribute to better posture in students, several ambiguities and questions remain unanswered, such as: Which intervention is more optimal and suitable for improving students' posture and preventing postural abnormalities? Is there a difference in the degree to which these interventions impact students' posture? Which training program is more sustainable? To address these questions, this study aims to compare the effects and durability of posture education and corrective games on the alignment of the thoracic and cervical spine, as well as the daily habits in children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe statistical population of this study was formed by elementary students with malalignments in the thoracic and cervical spine of Baharestan city (Iran). The participants were selected according to the available samples from a province. Participants were required to complete all the training sessions and attend all assessment sessions, and were asked to avoid intense physical activities during the study. As a result of these requirements, a total of 60 participants were assigned to this study and using simple and random method with computer-generated random numbers divided into posture education group (PE, n\u0026thinsp;=\u0026thinsp;20) corrective games group (CG, n\u0026thinsp;=\u0026thinsp;20) and control group (CON, n\u0026thinsp;=\u0026thinsp;20) groups. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A power analysis was conducted to determine the sufficient sample size of each group. The sample size was calculated based on a previous study by Rajabi, Minoonejad (23) with an alpha level of 0.05, effect size of 0.3 and an actual power (1-beta) of 0.80. The analysis (G \u0026times; Power, Version 3.1.9.2, University of Kiel, Germany) revealed that a sample size of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18 would be sufficient for each group to find significant effects between variables. With the possibility of participants dropping out, the number of participants was considered 10% more for each group.\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\u003eBaseline measurements (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\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=\"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=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003ePE training\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eCG training\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e11.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e136.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e135.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e136.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e6.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e35.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e23.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e*Significance level was considered p\u0026thinsp;\u0026ge;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eBMI: Body mass index; PE: Posture education; CG: Corrective games.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe inclusion criteria for the study included: 1) Gender of the participants: male only; 2) Willingness to participants: must express a willingness to take part in the research; 3) Age of participants: should be elementary students (ages 9 to 12); 4) General health: must not have experienced any acute or chronic diseases in the past six months; 5) Parental or legal guardian consent: written consent from a parent or legal guardian is required for participation; 6) No prior participation in similar programs: must not have engaged in similar training or sports programs in the past six months; 7) Spinal status: must be evaluated and approved by a specialist, confirming no significant spinal or neck abnormalities; 8) Ability to attend training sessions: must be capable of attending all training sessions and corrective games; 9) No use of effective medications: should not be taking medications that affect the musculoskeletal system; 10) Absence of psychological issues: must not have psychological problems that could impact their ability to participate in the research. The exclusion criteria for the study were as follows: 1) Regular absence: who miss more than three training sessions or games; 2) Change in health status: who develop acute or chronic diseases during the study period; 3) Failure to comply with instructions: who consistently disobey training guidelines and corrective game protocols; 4) School change: who change schools during the course of the research; 5) Voluntary withdrawal: who choose to discontinue their participation for any reason, with agreement from their parents or guardians. Before the initiation of the study, the participants (children individuals) and their parents were informed about the research procedures, and their written consent was obtained.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003earound here\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis study employed a three-armed cluster-randomized controlled trial design with convenience sampling. The study followed the CONSORT 2010 guidelines for reporting randomized trials [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The participants were pair-matched based on their malalignments and then randomly divided into three groups: posture education group (PE, n\u0026thinsp;=\u0026thinsp;20) corrective games group (CG, n\u0026thinsp;=\u0026thinsp;20) and control group (CON, n\u0026thinsp;=\u0026thinsp;20) groups. The randomization was performed using a computer-generated block randomization table, with a blinded member of the study team responsible for the allocation. The experimental groups participated in their programs, which involved 60-minute sessions, 2 days per week, for a duration of 2 months. The control group performed their regular daily activity. The study period spanned 11 weeks, with the following timeline: Week 1 - Familiarization period; Week 2 - Pre-test period; Weeks 3 to 10 - Training period; Week 11 - Post-test period. In addition, 3 months after post-test (follow-up) the participants were recruited to the school to reassess test results. Two weeks before the training period, a researcher communicated with the participants and standardized the training procedures. The weekly training sessions were co-created between the trainer and the participants, who were instructed to properly execute the prescribed exercises.\u003c/p\u003e \u003cp\u003eThe study was registered and allocated by the Clinical Trials (IRCT20250316065103N1). Also, the study was approved by the University of Guilan (Iran) IR.GUILAN.REC.1403.169. All experiments were conducted in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eThe participants underwent a total of 2 weeks of testing, which included both pre-tests and post-tests. To minimize the potential impact of circadian variations on the test results, the participants were tested at the exact same time of day (between 8 AM and 11 AM) and on the same day of the week as the pre-test session. Additionally, the testing was conducted during the same training hour as the pre-test, ensuring consistency in the testing conditions at the school.\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eThe participants' height was measured using a wall-mounted stadiometer (Seca 222, Terre Haute, IN) and recorded to the nearest 0.5 cm. Their body mass was measured to the nearest 0.1 kg using a digital scale (Tanita, BC-418MA, Tokyo, Japan) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKyphosis measurement: A flexible ruler was employed to measure the dorsal curvature of the spine due to its characteristics of being inexpensive, non-invasive, and quick. Participants were asked to uncover their upper bodies, allowing the researcher to observe and palpate the spine to identify the second and twelfth dorsal vertebrae. To locate the second dorsal vertebra, the participant was instructed to bend their head forward while standing. In this position, the researcher identified the most prominent vertebra, the seventh cervical vertebra, by touch. From there, two vertebrae below the seventh cervical vertebra were marked as the second dorsal vertebra. For the twelfth dorsal vertebra, the participant placed their hands on the edge of a table and shifted their weight forward into a semi-bent position. The researcher identified the twelfth vertebra by palpating the twelfth rib on both sides, following the rib's path upward and inward until it disappeared into the soft tissue. If there was uncertainty regarding the location of the twelfth vertebra, the subject was asked to bend forward while the researcher placed their thumbs at the suspected location. The movement felt during bending and extension confirmed the exact position of the twelfth vertebra, as it is adjacent to the junction of the thoracic and lumbar vertebrae, with the first lumbar vertebra located just below it. Once the points were identified, they were marked with an easily erasable marker. All measurements were taken while the participants stood in a relaxed position, distributing their weight evenly between both feet and looking straight ahead. After marking the points, the flexible ruler was placed along the spine, conforming to its shape without any gaps. The marked points were then transferred to the ruler. The ruler was carefully removed, and the curvature was drawn on paper with a pencil, marking the identified points on the drawn curvature. The distance between the two points (L) and the deep of the curvature (H) were measured using the ruler. These measurements were inserted into the formula \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\theta\\:}=4\\text{A}\\text{r}\\text{c}\\text{tan}2H/L\\)\u003c/span\u003e\u003c/span\u003e to calculate the kyphosis angle [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eForward head measurement; to measure the forward head angle using a goniometer, specific anatomical points were identified, including the tragus of the ear, the spinous process of the C7 vertebra, and the acromion prominence, which serve as reference points for assessing the position of the head and shoulders. The participant was placed in a natural standing position and instructed to focus their gaze on a point along the horizon. The goniometer was then positioned with its center at the tragus of the ear, one arm aligned parallel to an imaginary line drawn from the tragus to the C7 vertebra, and the other arm aligned with a horizontal line parallel to the ground. The angle obtained from this setup was recorded as the forward head angle. To minimize human error, each measurement was repeated three times, and the average value was calculated as the final data point. This method is widely used in corrective movement studies and postural analysis due to its simplicity, accuracy, and effectiveness in evaluating posture [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMeasuring the forward shoulder posture using the \"double square\" tool: the device utilized for measuring the forward shoulder position consists of a 40 cm composite ruler attached inverted to an additional surface, allowing for precise measurement of the distance from the anterior tip of the acromion to the wall. Studies have demonstrated that this method exhibits very high interrater reliability (ICC\u0026thinsp;=\u0026thinsp;0.99 and SEM\u0026thinsp;=\u0026thinsp;0.1 mm), underscoring the tool's accuracy and efficiency in assessing forward shoulder position [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The location of the anterior tip of the acromion on both the right and left shoulders of the participate was marked by touch and with a permanent marker. participates placed their heels against a wall and were instructed to maintain a \"military stance\" to ensure stability and prevent changes in body position. The double square tool was positioned so that one square was tangent to the wall. The second square was gently adjusted to contact the anterior tip of the acromion. The distance between the wall and the acromion tip was recorded to the nearest millimeter. This measurement was repeated three times for each shoulder, and the average was recorded for statistical analysis. After recording values in the military position, the participate returned to a natural and relaxed position, and the measurement process was repeated. To achieve the military position, participates were instructed to: Stand straight with shoulders pulled back and chest opened. Tuck the chin in slightly and keep the head straight. Place feet firmly on the floor while keeping the knees in a natural position. In this stance, participates were encouraged to maintain natural body balance without excessive muscle tension or unnatural bending. The military position serves as a standard reference for comparing the subject's natural position and helps prevent unwanted changes in body posture during the test [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003edaily habits measurement: to assess students' daily functional activities, a researcher-developed questionnaire based on the study of Emami, Shamsi Majelan and Norasteh (18) was utilized. The reliability of the questionnaire was evaluated using the Cronbach's alpha method, which yielded a reliability coefficient of 0.82, indicating a high level of internal consistency. Validity was confirmed by teachers and experts in corrective movements, ensuring that the content accurately reflects the intended measurements of daily activities. The questionnaire comprised 19 questions organized into three dimensions, with each dimension containing a specific number of questions related to daily functioning. Additionally, several questions included visual aids to enhance understanding and engagement. Scores ranged from 0 to 19, with scores closer to 0 indicating poorer performance in daily activities, while scores closer to 19 reflected better performance. This structured approach provides valuable insights into the students' daily lives, facilitating targeted interventions to improve their overall well-being [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostural education program\u003c/h2\u003e \u003cp\u003eThe training sessions incorporated in the current study are designed to address postural disorders, particularly among mothers and students, drawing from established \"back school\" programs prevalent in existing research. These health education initiatives aim to mitigate injuries and enhance the quality of life for individuals suffering from chronic musculoskeletal pain, notably spinal discomfort, by promoting appropriate activities of daily living. The program implemented in this study mirrors these objectives but is tailored to the audience: parents and guardians received educational materials over two sessions, while students were taught using simplified language for better comprehension [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe content of the training is structured into several key modules. The first module, \"Anatomy of the Human Body,\" covers the structure and function of various body parts, including bones, joints, and the spine, supplemented by illustrative slides. The second module focuses on \"Movement, Posture, Balance, and Body Awareness,\" emphasizing concepts such as the center of gravity and its relation to posture and movement, as well as static and dynamic balance [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe third module addresses \"Sitting,\" where participants analyze sitting positions in both classroom and home environments. This includes distinguishing between comfortable and correct sitting and exploring various sitting types, such as on the floor, at a desk, or in a chair. Practical exercises were conducted, where one student demonstrated different sitting positions while peers analyzed spinal alignment. Additionally, ergonomic solutions for computer desk setups were presented to mothers, encouraging students to optimize their workstations through simple adjustments, such as elevating the monitor or using a shoebox as a footrest [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fourth module, \"Picking Up, Putting On, and Carrying a Backpack,\" involved a hands-on analysis of commonly used items. Students practiced moving objects while the researcher monitored their techniques to prevent harmful movements. Discussions included the weight, size, and shape of backpacks, with individual assessments to adjust strap sizes and materials for optimal fit. Emphasis was placed on weight management, advising students on the organization of backpack contents\u0026mdash;placing heavier items closer to the body\u0026mdash;and demonstrating the correct lifting technique by recommending that backpacks be placed on elevated surfaces before being worn. To reinforce learning, students practiced various carrying styles, while peers provided feedback on their posture and technique [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCorrective games program\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the protocol for a series of corrective games designed to enhance physical fitness and postural alignment among participants. Each game focuses on specific muscle groups and includes details about objectives, participants, equipment, and variations for progressive difficulty. This structured approach not only fosters physical development but also encourages teamwork and awareness of posture, ultimately contributing to improved musculoskeletal health [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eSummarizes the protocol for a series of corrective games\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=\"char\" char=\"\u0026times;\" 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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGame Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObjective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePlaying Area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRequired Equipment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGame Description\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariations/Progression\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\u003eSnake Crawling Forward - Tent on the Ball\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStretching the large back, large chest, and small muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 groups of 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSwiss balls (size 45 or 55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticipants are divided into two groups. They start 20 meters apart, kneel, and place their forearms on the ball while maintaining a natural head and neck position. Subsequent participants pass over their partner to take position. The last member calls for movement, and the first group to cover the distance wins. The game is played in 2 rounds.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;2: 12-meter track length; walking/running\u003c/p\u003e \u003cp\u003e- Weeks 3\u0026ndash;4: 16-meter track with two 30-cm obstacles\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;6: 18-meter track with three 30-cm obstacles\u003c/p\u003e \u003cp\u003e- Weeks 7\u0026ndash;8: 16-meter track with lunges maintaining correct posture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCarrying a Book (Bag...) with the Head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStretching the pectoralis major/minor and internal rotators of the shoulder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 groups of 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOne-meter-long stick, a book or object\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticipants place a stick on their back and a book on their head. They move back and forth, passing the book to the next player. Each drop costs a point. The group that finishes faster with fewer errors wins. The game is played in 2 rounds.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;2: 12-meter track length\u003c/p\u003e \u003cp\u003e- Weeks 3\u0026ndash;4: 16-meter track with obstacles\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;6: 18-meter track with more obstacles\u003c/p\u003e \u003cp\u003e- Weeks 7\u0026ndash;8: Emphasis on correct form\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePassing the Ball Under the Bridge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStretching the pectoralis major/minor, internal rotators of the shoulder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 groups of 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVolleyball or training ball (35 cm diameter)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticipants assume a crab position and pass the ball under their bodies to teammates. The last person moves to the front after catching the ball. The team that reaches the end first wins.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;2: 12-meter path\u003c/p\u003e \u003cp\u003e- Weeks 3\u0026ndash;4: 16-meter path with obstacles\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;6: 18-meter path with increased obstacles\u003c/p\u003e \u003cp\u003e- Weeks 7\u0026ndash;8: Focus on maintaining form\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCatapult - Middle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening the parallelogram muscles, middle/lower trapezius, external rotators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSpiked exercise ball (45 cm), exercise band (1-1.2 m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOne group holds an exercise ball with bands while the other group throws balls at them. Points are deducted for hits. The game is played in three sets, with each player throwing three times before switching groups. The group with the fewest hits wins.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;4: Elbows flexed\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;8: Elbows opened for better hold on the ball\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCable Car - Crossing the River\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening the parallelogram and trapezius muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTwo ropes (15 m long)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTwo ropes are fixed at a height. Participants hook an elastic to the rope and pull themselves along it, ensuring shoulders and head touch the ground before moving on. The first team to finish wins.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;2: 6-meter path\u003c/p\u003e \u003cp\u003e- Weeks 3\u0026ndash;4: 7-meter path\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;8: 8-meter path\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnt (Carrying Luggage)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrengthening deep flexor muscles of the neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c4\"\u003e \u003cp\u003e20 \u0026times; 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBook or bag, exercise elastic (yellow and red)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParticipants balance a book or bag on their heads while pulling an elastic band. They pass the item to teammates at the end of the path. The first team to finish wins, with penalties for drops.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Weeks 1\u0026ndash;2: Use yellow elastic, walk/run\u003c/p\u003e \u003cp\u003e- Weeks 3\u0026ndash;4: Navigate over obstacles\u003c/p\u003e \u003cp\u003e- Weeks 5\u0026ndash;6: More obstacles\u003c/p\u003e \u003cp\u003e- Weeks 7\u0026ndash;8: Use red elastic with obstacles\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cem\u003earound here\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). The pre- and post-values for the dependent variables were analyzed to determine if the distributions were normal using the Shapiro-Wilk Normality test. Differences in all variables were analyzed using a 3 (group) x 3 (time) repeated measures ANOVA. When a significant F-value was achieved across time or groups, Bonferroni post-hoc procedures were performed to identify the specific pairwise differences. Additionally, the effects of training (effect size [ESs]) were calculated using Cohen's d [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the primary stage of the study, 68 male children recruited in the study and then based on inclusion and exclusion criteria 60 participants were included and allocated into 3 groups (n\u0026thinsp;=\u0026thinsp;20 for each group). To be included in the final analyses, participants were required to complete all the training sessions and attend all assessment sessions. As a result of these requirements, no participants were excluded from the study. This indicates that all individuals who met the criteria were able to participate fully. Therefore, 20 participants for each group were included for final analysis (Flowchart).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFlowchart around here\u003c/h2\u003e \u003cp\u003eBefore training, no significant differences were observed for dependent variables in groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No significant changes in the CON were observed in all variables after training period (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The test-retest reliability coefficient of these tests was r\u0026thinsp;\u0026ge;\u0026thinsp;0.89. To assess intraclass correlation coefficient (ICC), two measurements were made with 48 h apart and the ICC for the tests was \u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026ge;\u0026thinsp;0.89.\u003c/p\u003e \u003cp\u003eThere was a significant interaction between group and time for kyphosis (F\u0026thinsp;=\u0026thinsp;5.2, p\u0026thinsp;=\u0026thinsp;0.01), forward head posture (F\u0026thinsp;=\u0026thinsp;4.2, p\u0026thinsp;=\u0026thinsp;0.02), forward shoulder posture (F\u0026thinsp;=\u0026thinsp;3.9, p\u0026thinsp;=\u0026thinsp;0.001), and daily habits (F\u0026thinsp;=\u0026thinsp;6.1, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eBoth the PE and CG showed significant improvements in kyphosis (p\u0026thinsp;=\u0026thinsp;0.01 for PE, p\u0026thinsp;=\u0026thinsp;0.02 for CG), forward head posture (p\u0026thinsp;=\u0026thinsp;0.02 for PE, p\u0026thinsp;=\u0026thinsp;0.04 for CG), forward shoulder posture (p\u0026thinsp;=\u0026thinsp;0.001 for PE, p\u0026thinsp;=\u0026thinsp;0.02 for CG), and daily habits (p\u0026thinsp;=\u0026thinsp;0.02 for PE, p\u0026thinsp;=\u0026thinsp;0.03 for CG) after an 8-week training intervention compared to the CON group. However, after a 3-month detraining period, the changes in both the PE and CG were found to be statistically insignificant. The p-values for kyphosis (PE\u0026thinsp;=\u0026thinsp;0.23, CG\u0026thinsp;=\u0026thinsp;0.33), forward head posture (PE\u0026thinsp;=\u0026thinsp;0.56, CG\u0026thinsp;=\u0026thinsp;0.36), forward shoulder posture (PE\u0026thinsp;=\u0026thinsp;0.36, CG\u0026thinsp;=\u0026thinsp;0.43), and daily habits (PE\u0026thinsp;=\u0026thinsp;0.23, CG\u0026thinsp;=\u0026thinsp;0.16) indicate that these differences were not significant (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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\u003eSignificant and effect size for the variables in the groups [n\u0026thinsp;=\u0026thinsp;60].\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\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=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eTime point values\u003c/p\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eEffect size (95% CI) and p-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3-month post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre to post ES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePost to 3-month post ES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eKyphosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.35\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e29.17\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026thinsp;=\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.12 (0.37 to 1.86) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.14 (-0.46 to -0.23) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.79\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e29.11\u0026thinsp;\u0026plusmn;\u0026thinsp;6.11\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.21 (0.48 to 1.79) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.19 (-0.56 to -0.28) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCON\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026times;T\u0026thinsp;=\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eForward head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.17\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e30.43\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026thinsp;=\u0026thinsp;0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.48 (0.36 to 1.86) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.21 (-1.08 to -0.68) b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.86\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e31.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.26 (0.26 to 1.56) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.24 (-1.14 to -0.62) b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCON\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e35.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026times;T\u0026thinsp;=\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eForward shoulder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.43\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e11.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026thinsp;=\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.39 (0.14 to 1.54) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.23 (-0.98 to -0.77) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.43*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e11.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.42 (0.16 to 1.63) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.43 (-1.12 to -0.64) b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCON\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e16.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026times;T\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePattern of daily activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.19*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e13.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026thinsp;=\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.98 (0.38 to 1.4) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.24 (-1.11 to 0.86) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.43*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e14.43\u0026thinsp;\u0026plusmn;\u0026thinsp;5.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.01 (0.66 to 1.78) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.21 (-1.1 to 0.89) a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCON\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e10.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eG\u0026times;T\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ePE: Posture education; CG: Corrective games., CON; control; G: group; T: time; CI: confidence interval; a: trivial; b: small; c: moderate; d: large ES. *Significant differences compared to pre and CON (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), \u0026dagger; significant differences compared to post (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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cem\u003earound here\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was designed to examine the effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children. The findings of this study indicated that both EP and CG groups decreased kyphosis angle, forward head posture, forward shoulder posture and improved daily habits of children. Also, results indicated that following the 3-month follow period no significant changes were observed in the measured variables.These findings are in line with results of previous studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] which examined the effects of EP or CG on spine posture and found significant effects.\u003c/p\u003e \u003cp\u003eIn explaining the impact of the EP on children's spines, it can be stated that this initiative functions as a targeted educational intervention designed to enhance awareness of proper body mechanics and postural alignment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This educational framework focuses on increasing awareness regarding optimal postural alignment, rectifying postural deviations, and promoting sustainable movement patterns [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. By fostering awareness of correct posture, the program aims to mitigate the risk of developing postural deformities such as kyphosis, forward shoulder posture, and forward head posture [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It emphasizes the importance of educating students about appropriate postural behaviors and the biomechanical principles governing body use in various environments [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Instruction encompasses a wide range of activities, from proper sitting techniques to ergonomic practices for carrying loads and utilizing technological devices. Integrated into physical education curricula, the EP utilizes sports and physical activities to reinforce correct movement habits [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Through this comprehensive approach, the program effectively equips children with the knowledge and skills necessary to maintain proper posture, thereby reducing the likelihood of spinal deformities and promoting overall musculoskeletal health.\u003c/p\u003e \u003cp\u003eAdditionally, in discussing the effect of the CG on children's spines, it can be noted that the training regimen for the corrective games group comprised a variety of movements, including activities such as \"wooden houses,\" \"trying to get up,\" \"airplanes,\" and \"mice and cats,\" all designed to elongate shortened muscles [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, exercises such as \"carrying a tennis ball,\" \"judging a blackboard,\" \"pull-pull,\" \"broken knee,\" and \"trying to get up\" were employed to enhance muscle strength [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These movements significantly contributed to the improvement of spinal posture complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A key mechanism behind the effectiveness of corrective games lies in their engaging nature and the collaborative group dynamics, which serve to motivate participants to engage in the exercises [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Corrective games represent a more accessible and effective approach for enhancing spinal posture. Their inherent motivational aspects, stemming from their enjoyable nature, make them particularly suitable for children, aiding in the correction of maladaptive spinal postures [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the long-term sustainability of both programs, it can be stated that the focus is on correcting body alignment, strengthening the supporting muscles, and enhancing shoulder stability, while also emphasizing the importance of proper movement patterns [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These elements are crucial as they contribute to an increased awareness of body posture in a corrected and controlled manner, facilitated by the nervous system [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. By fostering this awareness, the programs promote lasting effects on spinal health and overall musculoskeletal function [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The integration of these principles ensures that participants not only achieve immediate improvements but also develop the necessary skills and habits to maintain these benefits over time, ultimately supporting sustained spinal alignment and stability [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, the results of the study indicated that both the EP and CG exhibited improvements in the daily habits, with no notable difference in the effectiveness of each program in enhancing daily habits. These findings align with previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], which investigated the effects of EP and CG on daily activity patterns and reported significant positive outcomes. This consistency in results suggests that both programs are effective in promoting healthier daily behaviors.\u003c/p\u003e \u003cp\u003eThe effective application of body mechanics, as demonstrated in EP and CG classes, enhances the musculoskeletal system's adjustments by improving balance and distributing the effort needed for daily activities, which can help alleviate pain and slow degenerative processes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, this relief relies on the intricate interactions between biomechanical and neuromuscular functions. Changing habits is challenging, as postural habits are deeply ingrained in both movement patterns and mental frameworks [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Interventions aimed at altering poor postural habits must create opportunities for reflection and understanding of the associated postures and movements. It's also crucial to consider the psychological and cultural factors that influence the formation of postural habits [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. For a habit to change, individuals need to learn to observe and interpret the sensations produced by their movements, which is the goal of EP and CG interventions [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The EP methodology encourages greater autonomy for individuals in addressing posture-related issues in their daily lives [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The educational activities highlighted in this study are designed to promote proper postures through habit modification, serving as a vital approach to health promotion [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These programs should be tailored to address lifestyles and behaviors that contribute to or exacerbate health problems, allowing for individual modification.\u003c/p\u003e \u003cp\u003eAnother significant aspect addressed in this study is the examination of the impact of time on the retention of knowledge and habits acquired following the intervention. Consistent with previous research [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], our findings demonstrate that improvements in knowledge and habits were maintained compared to pre-test levels. Although our follow-up assessment occurred three months post-intervention, studies with extended follow-up durations\u0026mdash;ranging from one year [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] to eight years [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u0026mdash;have also reported comparable results. This sustained improvement over time suggests a positive long-term effect of interventions on both knowledge and habits.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and future scope\u003c/h2\u003e \u003cp\u003eThis study has several methodological limitations that deserve attention. Firstly, the findings are specific to male children aged 9\u0026ndash;12, highlighting the need for further research to determine if these results can be generalized to female children across different age groups. Additionally, while the use of a questionnaire to assess daily activities is valuable for systematically capturing subjective perceptions due to its ease of use and low cost, it may introduce bias. This bias arises because responses are heavily influenced by the participants' perceptions and cognitive abilities. Furthermore, questionnaires cannot verify how well individuals incorporate theoretical knowledge into practice or how this knowledge translates into movement, which could be assessed more effectively through video analysis of dynamic posture.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, both the EP and CG interventions resulted in significant reductions in kyphosis angle, forward head posture, forward shoulder posture while also enhancing daily activity patterns without notable differences in effectiveness between the two programs. The findings highlight the importance of fostering awareness of proper body mechanics and postural alignment, which are essential for preventing postural deformities. Additionally, the sustainability of these improvements suggests that participants developed lasting skills and habits that promote ongoing spinal health. Overall, the study reinforces the value of integrating educational and engaging physical activities into curricula to support children's musculoskeletal well-being.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePosture education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCorrective games\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the University of Guilan (Iran) IR.GUILAN.REC.1403.169. All experiments were conducted in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has used the principles of the Declaration of Helsinki, the general guide to ethics in research with human subjects, and its governing regulations. Before the initiation of the study, the participants (children individuals) and their parents or legal guardians were informed about the research procedures, and their written consent was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were informed of the purpose and procedure of this study, and informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no funding from any agency in the public, commercial, or not-for-profit sector.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.B. \u0026amp; A.SHM.: data acquisition and analysis. M.B. \u0026amp; A.SHM.: data interpretation. M.B. \u0026amp; A.SHM.: wrote the main manuscript text and prepared the figures. M.B. \u0026amp; A.SHM.: conception/design of the work. M.B. \u0026amp; A.SHM.: reviewed and contributed to the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researcher would like to express gratitude towards all the participants that contributed to conducting the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSharma S, Rawat V. The Importance of Body Posture in Adolescence and its Relationship with Overall Well-being. Indian J Med Specialities. 2023;14(4):197\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatist\u0026atilde;o MV, Moreira RFC, Coury HJCG, Salasar LEB, Sato TO. Prevalence of postural deviations and associated factors in children and adolescents: a cross-sectional study. 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Comparison of the Effect of Functional Corrective Exercises and Corrective Games on Upper Cross Syndrome in 10\u0026ndash;13 Year-Old Boys. Sci J Rehabilitation Med. 2020;9(4):19\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaneshjoo A, Mousavi Sadati SK, Pourahmad F. Effect of corrective exercise vs corrective games on upper crossed syndrome in female students. Phys Treatments-Specific Phys Therapy J. 2021;11(1):13\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajabi F, Minoonejad H, Seidi F, Rajabi R. To Compare the Effect and Sustainability of a Course Corrective Games with Selected\u0026lrm; Corrective Exercise on 10\u0026ndash;12 Aged Boys with Hyper Thoracic Kyphosis. J Paramedical Sci Rehabilitation. 2022;11(3):29\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchulz KF, Altman DG, Moher D, Group* C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTipton PH, Aigner MJ, Finto D, Haislet JA, Pehl L, Sanford P, Williams M. Consider the accuracy of height and weight measurements. Nursing2023. 2012;42(5):50\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorres-Cusihuaman L, Bravo-Cucci S. Association between thoracic kyphosis and forward head posture in teenagers: an analytical cross-sectional study. Middle East J Rehabilitation Health Stud. 2023;10(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGray K, Dalal R, Weaver JD, Randolph S. Quantitative measurements of forward head in college-aged students: a conformational study of intra-rater and inter-rater reliability of a novel posture measuring device. J Bodyw Mov Ther. 2021;26:233\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. J sport rehabilitation. 2006;15(1):58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarvalho LA, Aquino CF, Souza TR, Anjos MTS, Lima DB, Fonseca ST. Clinical measures related to forward shoulder posture: a reliability and correlational study. J Manip Physiol Ther. 2019;42(2):141\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinghelli B, Nunes C, Oliveira R. Back School Postural Education Program: Comparison of Two Types of Interventions in Improving Ergonomic Knowledge about Postures and Reducing Low Back Pain in Adolescents. Int J Environ Res Public Health. 2021;18(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBartz PT, Vieira A, Noll M, Candotti CT. Effectiveness of the back school program for the performance of activities of daily living in users of a basic health unit in Porto Alegre, Brazil. J Phys Ther Sci. 2016;28(9):2581\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinghelli B, Nunes C, Oliveira R. Effectiveness of a Back School and Postural Education Program on the improvement of literacy about postures and low back pain in adolescents: A 1-year follow-up study. J Orthop Sci. 2021;26(4):543\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMi\u0026ntilde;ana-Signes V, Monfort-Pa\u0026ntilde;ego M, Rosaleny-Maiques S. Improvement of knowledge and postural habits after an educational intervention program in school students. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAra\u0026uacute;jo CL, Moreira A, Carvalho GS. Postural education programmes with school children: A scoping review. Sustainability. 2023;15(13):10422.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBettany-Saltikov J, McSherry R, Van Schaik P, Kandasamy G, Hogg J, Whittaker V, et al. PROTOCOL: School‐based education programmes for improving knowledge of back health, ergonomics and postural behaviour of school children aged 4\u0026ndash;18: A systematic review. Campbell Syst Reviews. 2019;15(1\u0026ndash;2):e1014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMandz\u0026aacute;kov\u0026aacute; M, Slov\u0026aacute;kov\u0026aacute; M. The Intervention Program effect on the Quality of Children\u0026rsquo;s Body Posture at Elementary Education Level. Sport Mont. 2023;21(3):57\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikhhoseini R, Kamelan M. Child-centered Corrective Exercises: A Multidisciplinary Approach to Posture Improvement in Children. J Pediatr Rev. 2025;13(1):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrygus I, Nesterchuk N, Hrytseniuk R, Rabcheniuk S, Zukow W. Correction of posture disorders with sport and ballroom dancing. Медичні перспективи. 2020;25(1):174\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVidal J, Borras P, Ortega F, Cantallops J, Ponseti X, Palou P. Effects of postural education on daily habits in children. Int J Sports Med. 2011;32(04):303\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalmes-Panades AM, Vidal-Conti J, editors. Effects of postural education program (PEPE Study) on daily habits in children. Frontiers in Education; 2022: Frontiers Media SA.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesouzart G, Filgueiras E. PostureMind\u0026mdash;Postural Education in Back Pain and Postural Habits of Children and Teenagers. Occupational and Environmental Safety and Health. Springer; 2023. pp. 31\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeldhof E, Cardon G, De Bourdeaudhuij I, Danneels L, Coorevits P, Vanderstraeten G, De Clercq D. Effects of back posture education on elementary schoolchildren\u0026rsquo;s back function. Eur Spine J. 2007;16:829\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVidal J, Borras PA, Ponseti FJ, Cantallops J, Ortega FB, Palou P. Effects of a postural education program on school backpack habits related to low back pain in children. Eur Spine J. 2013;22:782\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026eacute;ndez FJ, G\u0026oacute;mez-Conesa A. Postural hygiene program to prevent low back pain. Spine. 2001;26(11):1280\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeldhof E, Cardon G, De Bourdeaudhuij I, De Clercq D. Back posture education in elementary schoolchildren: a 2-year follow-up study. Eur Spine J. 2007;16:841\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolphens M, Cagnie B, Danneels L, De Clercq D, De Bourdeaudhuij I, Cardon G. Long-term effectiveness of a back education programme in elementary schoolchildren: an 8-year follow-up study. Eur Spine J. 2011;20:2134\u0026ndash;42.\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":"Posture Education, Corrective Games, Spine, Posture, Daily Activities","lastPublishedDoi":"10.21203/rs.3.rs-6330673/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6330673/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThis study aims to compare the effects of posture education and corrective games on the alignment of the thoracic and cervical spine, as well as the daily habits in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003eThe statistical population of this study was formed by elementary students with malalignments in the thoracic and cervical spine of Baharestan city (Iran). A total of 60 participants were assigned to this study and using simple and random method with computer-generated random numbers divided into posture education group (PE, n= 20) corrective games group (CG, n= 20) and control group (CON, n= 20) groups. Kyphosis angle, forward head posture and forward shoulder posture measured with a flexible ruler, goniometer, and double square, respectively. Also, daily habits measured with students' daily functional activities questioner.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eBoth the PE and CG showed significant improvements in kyphosis (p = 0.01 for PE, p = 0.02 for CG), forward head posture (p = 0.02 for PE, p = 0.04 for CG), forward shoulder posture (p = 0.001 for PE, p = 0.02 for CG), and daily habits (p = 0.02 for PE, p = 0.03 for CG) after an 8-week training intervention compared to the CON group. However, after a 3-month detraining period, the changes in both the PE and CG were found to be statistically insignificant (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn conclusion, both the EP and CG interventions significantly improved kyphosis, forward head, and shoulder posture, as well as daily activity patterns, without notable differences between them. Additionally, the sustainability of these improvements suggests that participants developed lasting skills and habits that promote ongoing spinal health. Overall, the study reinforces the value of integrating educational and engaging physical activities into curricula to support children's musculoskeletal well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRCT registration number:\u003c/strong\u003e IRCT20250316065103N1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration date: \u003c/strong\u003e2025-03-25\u003cstrong\u003e \u003c/strong\u003e(Retrospectively registered)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Id: \u003c/strong\u003e82539\u003c/p\u003e","manuscriptTitle":"The effect and durability of postural education and corrective games on the alignment of the thoracic and cervical spine and the daily habits in children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-16 09:19:28","doi":"10.21203/rs.3.rs-6330673/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":"eb415720-4a62-417a-bb69-475e66ce084b","owner":[],"postedDate":"April 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-09T08:53:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-16 09:19:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6330673","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6330673","identity":"rs-6330673","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}