Effect of the cervical and thoracic "Daoyin" training on posture and pulmonary function in patients with upper crossed syndrome: A randomized controlled trial

Effect of the cervical and thoracic "Daoyin" training on posture and pulmonary function in patients with upper crossed syndrome: A randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of the cervical and thoracic "Daoyin" training on posture and pulmonary function in patients with upper crossed syndrome: A randomized controlled trial Yue Guo, Ming Li, Chaowei Xie, Xiaoyan Liu, Yushan Chen, Jun Yang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4349182/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background: With the growing ubiquity of electronic devices, the incidence of upper crossed syndrome (UCS) is increasing every year and tends to affect younger populations. The study designed to assess the effect of cervical and thoracic "Daoyin" training on pain, posture, pulmonary function, cervical range of motion, and emotional state in college students with UCS. Methods: We conducted a parallel-group randomized control study, assigning 74 college students to intervention group (IG) and control group (CG) at Fujian Medical University, Fujian, China. Instructed cervical and thoracic "Daoyin" training was given to students in the IG for eight weeks, five days a week for 45 minutes, whereas students in the CG continued with their usual activities. Primary outcomes, including forward head and shoulder angles, pain and cervical spine function, as well as secondary outcomes, such as pulmonary function, cervical range of motion and emotional state were measured at baseline and at a follow-up of eight weeks. These measurements were conducted using photogrammetry, visual analog scale(VAS), Neck Disability Index(NDI), pulmonary function, cervical range of motion test and Self-rating Anxiety Scale, respectively. We analyzed the effect of cervical and thoracic "Daoyin" training on college students with UCS using a general linear model. Results: Analyses using general linear model revealed that the IG had a obvious improvement in the forward head angle, forward shoulder angle, and emotional state compared with the CG from baseline to eight weeks post-intervention (F=11.415, P<0.001; F=5.490, P=0.020; F=4.411, P=0.037). In addition, there were significant improvements in VAS (d=0.854, P<0.001), NDI (d=0.754, P=0.005), pulmonary function (forced vital capacity (FVC) (d=0.531, P=0.025), forced expiratory volume in 1 second (FEV1) (d=0.521, P=0.028), FEV1/FVC (d=0.540, P=0.034), maximal voluntary ventilation (MVV) (d=0.888, P<0.001) and cervical range of motion in forward flexion (FF) (d=0.353, P=0.029) at the end of 8-week intervention in IG. No side-effects were observed in this study. Conclusion: Cervical and thoracic “Daoyin” training can improve the pain, posture, cervical spine function, pulmonary function, cervical range of motion in forward flexion , and emotional state of college students with UCS to some extent. Trial registration: ChiCTR2300072669 (20/06/2023), Prospective registration, www.chictr.org.cn College students Exercise Musculoskeletal diseases Postural alignment Lung function Figures Figure 1 Figure 2 Introduction With the advent of the Internet, mobile phones and other electronic devices have become an integral component in everyone’s lives, especially students, whether it is to attend classes, make purchases, conduct transactions, or have social interactions[ 1 ]. The continuous use of these electronic devices can easily result in abnormal postures[ 2 ]. Neuromuscular imbalances can manifest as abnormal postures and can be related to some musculoskeletal conditions[ 3 ]. Upper crossed syndrome (UCS), first identified by Dr. Vladimir Yanda(1979)[ 4 ], is one of the most frequently cited complications with modern technological life, which is characterized by weakened middle and lower trapezius, scalenes, deep cervical flexors and serratus anterior at the same time as the rhomboids, as well as tightness in the upper trapezius, pectoralis minor and major and levator scapulae muscles[ 5 ]. It mainly leads to muscle imbalances, which eventually manifest in both tonic and phasic muscles[ 6 ]. The main causative factors include poor head and neck posture[ 7 ], abnormal breathing pattern, psychological problems of female adolescents, and unreasonable fitness methods[ 8 ]. People with UCS may display characteristics including forward head posture (FHP), round shoulders, elevated and prolonged shoulders and limited mobility of the cervical spine. These conditions are concomitantly related to neck and shoulder pain[ 9 ]. In UCS, pain is easily relapsing and long-lasting. The long-term effects of chronic pain on patients’ mental health are profound, and UCS patients are prone to negative emotions such as anxiety, which may severely interfere with their quality of life[ 10 ]. FHP and rounded shoulders are abnormal postures that are typical of UCS patients. These conditions may lead to an increase in upper thoracic kyphosis, which can result in a decrease in the volume of the thoracic cage[ 11 ] as well as impede the motion of the diaphragm and other muscles of active respiration[ 12 ]. Abnormal postures typically lead to a reduction lung volumes and capacities, which in turn affects chest expansion and alveolar ventilation, resulting in a decrease in oxygen partial pressure and a reduction in exercise tolerance and respiratory efficiency.[ 13 ]. To treat UCS patients, therapists have used a variety of approaches such as muscle energy techniques[ 14 ], kinesio taping[ 15 ], stretching exercises[ 16 ], pressure biofeedback[ 17 ], and other techniques. While these approaches appear to work in clinical practice, they have a few limitations. The treatment must be carried out by a professional rehabilitation therapist to complete the operation, and the patient cannot do it alone. Moreover, the costs are prohibitive and may not be affordable for certain patients. In the context of traditional Chinese medicine, in addition to traditional therapies such as acupuncture[ 18 ], Chinese traditional exercise qigong was also found to play a positive role in restoring musculoskeletal balance in UCS patients[ 19 ]. Nevertheless, these exercises are all based on the existing exercise guidance training, which are poorly targeted for patients with UCS. On the basis of traditional Chinese qigong, cervical and thoracic “Daoyin” training emphasizes on training the neck and shoulder muscles of patients and correcting muscle imbalance and abnormal posture. In this study, we evaluate the effect of cervical and thoracic “Daoyin” training on posture, pain, function, range of motion, pulmonary function, and emotional state in college students with UCS. Methods Study design A parallel-group randomized controlled trial was used in this study. The trial has been registered with the Chinese Clinical Trial Registry since June 20, 2023 (ChiCTR2300072669). It was also approved ethically by the Ethical Review Committee of Biomedical Research, Fujian Medical University [(2023) Fuyi Ethics Review No. (102)]. The Helsinki Declaration was followed in all aspects of the experiments. The study's reporting adhered to the rigor CONSORT guidelines. Participants We recruited 74 students of Fujian Medical University diagnosed with UCS. These students were recruited between Sep 1 and Oct 5, 2023, through posters published by the investigators. If a participant met the following requirements, they were eligible to participate. (1) They were full-time college students of age 18–26 years; (2) Their condition satisfied the diagnostic criteria raised by Asian Fitness Society for UCS, i.e., (i) The corner of the eye and the upper corner of the ear are not in the same horizontal plane; (ii) The two earlobe lines are in front of the two acromion lines; (iii) The left and right acromiums are not equidistant from the midline of the human body. (iv) The distance between the scapula and the spinous process of the spine exceeds the width of the four fingers of the body finger; and (v) The cervical C7-posterior occipital carina curvature gap was larger than the four finger width of the body finger; (3) They provided the informed consent. With regard to exclusion criteria, individuals were considered ineligible if they engaged in additional exercise in two weeks, which was likely to affect the results of the research. Individuals with a history of spine, shoulder fractures, surgery, or other diseases, or having severe cardia-cerebrovascular disease were also excluded. Dropout criteria were considered if three consecutive interventions were unsuccessful, the participant was unable to complete follow-up testing, or other factors were present that could influence the study results. Randomization Block randomization in a 1:1 ratio was generated using the SPSS 27.0 program, and allocation concealment was accomplished by opening sequentially numbered opaque sealed envelopes. The CG or the IG group to which the subject was randomly allocated was specified on a card inside. During the experiment, outcome assessors were kept unaware of the groups they were assigned to. Figure 1 depicts the flowchart for the study. Intervention All the IG participants received instructions from two professional trainers to conduct the cervical and thoracic “Daoyin” training. The time (Monday to Saturday at 5:00–5:45 p.m. or 9:00–9:45 p.m.) and location (a classroom of Fujian Medical University) of exercise were consistent and fixed. The training was conducted five times a week for two months. The cervical and thoracic “Daoyin” training in this study consisted of the following five movements: (1) Dantian Gong (2) Turtle shrinking its neck (3) Roc spreading its wings (4) White goose stretching its neck (5) Tiger lying (Additional file 1). Supplemental Table S1 provides specifics on how cervical and thoracic "Daoyin" training works. The interval of each movement was 30–60 s, and the duration was 45min. The CG participants were instructed to maintain daily activities and not partake in any further sports. Health education was given to all participants before the start of the experiment. The contents included UCS - related concepts, etiology, hazards, mitigation methods, and precautions. Outcomes At baseline, the following demographic characteristics (age, weight, height, BMI) were assessed. Three researchers who were not involved in the group allocation process collected data and variables immediately prior to group allocation and following the intervention. Primary outcome measures included FHA and FSA, pain score, and cervical spine function assessment. Secondary outcome measures included pulmonary function test, cervical range of motion measurement, and emotional state assessment. Forward head and shoulder angles The PA200LE body monitoring and analysis system (The Big Sports Co. Ltd, Japan) was used to evaluate the Forward Head Angle (FHA) and Forward Shoulder Angle (FSA). In a separate room, participants stood on the plantar platen with the camera positioned 2.4 m in front of the plate, and the camera's Red Cross was calibrated to coincide with the white cross on the plantar platen before evaluation began. During the postural assessment, participants wore tight fitting clothing and red marker points for photo image analysis were attached to the spinous process of the C-7 spinous, right tragus, and acromion. Participants stood with their feet 10 cm apart on the plantar platen in the side, with the fifth metatarsal eminence of their feet aligned with the white line in the sagittal direction of the plantar platen, looking forward with their hands naturally hanging at their sides. A straight line was made perpendicular to the ground through the C-7 spinous process, and then the tragus and acromion were connected with the C-7 spinous process respectively. ∠1 was FHA and ∠2 was FSA (Fig. 2 ) .The Angle Meter software was downloaded on the mobile phone, and the pictures were put into the software for analysis, the angles of FHA and FSA were calculated, and the final data were obtained[ 20 ]. Pain score Using the VAS, which consists of a 10 cm straight line, the degree of pain was assessed, with 0 on one end meaning “painless” and 10 on the other meaning “probably the most intense pain.” Patients marked their own pain on this straight line, with higher scores indicating more pain[ 11 , 21 ]. Cervical spine function assessment The NDI was used to evaluate the cervical spine's functionality. It is a self-rated questionnaire, most commonly used in clinical studies related to neck pain. The evaluation took into account how neck discomfort affected a person's capacity to do activities of daily life[ 22 ]. The NDI scale consists of 10 items, each of which is scored from 0 to 5. More dysfunction is indicated by a higher score. Pulmonary function test BTL-08 Spiro (BTL, United Kingdom) was used to measure lung function. Calibration was performed before measurement, and the error was within 3%. At the same time, we ensured that the test was carried out in a relatively non-interference state. Before the test, 74 participants were uniformly trained on relevant test methods, and the formal test could only be started after they have mastered the correct test methods. The parameters of lung function test included forced vital capacity (FVC), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), and maximal voluntary ventilation (MVV) measured value as a percentage of estimated value (real/predicted). We tested each parameter thrice and took the mean value each time. Cervical range of motion measurement The active range of motion of the cervical spine was measured using a medical human joint protractor (BWP-JDC, China), which consisted of a fixed arm, a movable arm, and an axis[ 23 ]. Before measurement, the osseous markers of the cervical spine were required to be determined. The axis of the protractor was aligned with the joint axis. The fixed arm was parallel to the shaft of the proximal bone of the joint, and the movable arm was parallel to the shaft of the distal bone. Each of the six primary cervical spine movements was measured, including forward flexion (FF) and backward extension (BE) in coronal plane, left lateral flexion (LLF) and right lateral flexion (RLF) in sagittal plane, as well as left rotation (LR) and right rotation (RR) in transverse plane. Emotional state assessment Emotional states were evaluated with the Self-Rating Anxiety Scale (SAS), a self-assessment tool for anxiety symptoms, which can reflect the subjective feelings of adults with anxiety tendencies. There are 20 questions in this scale, including 15 forward scores and five reverse scores. We multiplied the total assessed score by 1.25 to give the final score. Higher scores indicate higher anxiety[ 24 ]. Sample size calculation Based on the results of an earlier study of upper crossed syndrome, the FSA was 44.60 ± 7.54 and 38.95 ± 4.81 degrees in the CG and the IG, respectively, at the end of the intervention. Using the GPower3.1 software, the trial required 74 participants (37 in each group) to be able to perform a statistical test with the assumption of a type I error of 5% (α = 0.05), 95% power (β = 0.05), and the allowance of a dropout rate of 10%. Statistical analysis All statistical analyses were performed using SPSS 27.0 software. Means and standard deviations were used to describe results for continuous variables, while frequencies and percentages were used to provide results for categorical variables. P < 0.05 and P < 0.01 were used to determine if results were statistically different and significantly different. The Shapiro - Wilk test test was used to determine if the data distribution was normal. Before and after the intra-group differences were compared by paired-sample t-test (normal distribution) and Wilcoxon rank sum test (skewed distribution). The independent-samples t-test (normal data distribution) and Mann–Whitney U test (skewed distribution) were used to compare differences between groups. Cohen's d was used to calculate the between-group effect sizes, with effect sizes of 0.2, 0.5, and 0.8 regarded as small, medium, and large, respectively. The intervention effect between the CG and the IG group from baseline to 8-week post-intervention was analyzed by using the general linear model. Results Baseline characteristics of participants As stated earlier, total of 74 participants were recruited and allocated equally to either the CG or the IG. The trial was completed by all participants, and all were included in the analysis. Throughout the intervention period, no injuries or adverse events were seen or reported by participants.The baseline data were balanced and comparable, and no statistical differences were found between the two groups with regard to the proportion of sex, mean age, and BMI (Table 1 ). Table 1 Characteristics of participants at baseline. Characteristics Intervention(n = 37) Control (n = 37) t/χ2 value P-value Age (years) 19.00 ± 0.97 18.92 ± 0.86 −0.399 0.690 Gender (Male/Female, n) 22/15 15/22 2.649 0.104 BMI (kg/m2) 21.05 ± 3.23 21.10 ± 3.02 −0.038 0.970 Differences between groups were not significant (all P > 0.05). Primary outcomes Table 2 presents the values for our primary outcomes. The values of FSA and FHA varied significantly between groups, with medium (d = 0.579, P = 0.008) and high (d = 0.815, P < 0.001) effect sizes in post-intervention measurements. FHA also decreased in the control group, and the difference was statistically significant after 8 weeks, indicating that the content of the health education had a positive effect. A significant difference was found in NDI and VAS values between the groups, with medium (d = 0.754, P = 0.005) and high (d = 0.854, P < 0.001) effect sizes in post-intervention measurements. Our general linear model analysis revealed that FHA and FSA were less in the IG compared with the CG from baseline to eight weeks after the intervention, with the significant group by time effect (F = 11.415, P < 0.001; F = 5.490, P < 0.020). Table 2 Primary outcomes by group at baseline and 8 weeks. Outcome Intervention(n = 37) Control (n = 37) Comparison between groups t/P-value Between-group effect size Cohen’s d Time × group interaction F/P-value Primary outcomes Forward Head Angle (FHA) Baseline 42.15 ± 5.34 40.63 ± 5.11 1.245/0.217 8-week intervention 33.91 ± 5.70 ## 38.27 ± 4.98 ## −3.649/<0.001** 0.815 11.415/<0.001 Forward Shoulder Angle (FSA) Baseline 29.60 ± 13.40 27.43 ± 10.37 −0.780/0.438 8-week intervention 21.53 ± 13.41 ## 28.83 ± 11.70 −2.649/0.008** 0.579 5.490/0.020 Visual Analogue Scale (VAS) Baseline 2.51 ± 1.52 2.62 ± 1.86 −0.088/0.930 8-week intervention 1.35 ± 1.09 ## 2.70 ± 1.96 −3.313/<0.001** 0.854 5.305/0.023 Neck Disability Index (NDI) Baseline 8.59 ± 5.17 9.03 ± 5.94 −0.130/0.896 8-week intervention 5.08 ± 3.88 ## 9.14 ± 6.54 −2.830/0.005** 0.754 4.051/0.046 # Significant differences from baseline (P < 0.05). ## Significant differences from baseline (P < 0.01). * Significant differences between groups (P < 0.05). ** Significant differences between groups (P < 0.01). Secondary outcomes The values for our secondary outcomes are presented in Table 3 . After the eight-week intervention period, FF, FVC, FEV1, FEV1/FVC and MVV of the IG were significantly better than those of the CG, with small (d = 0.353, P = 0.029), medium (d = 0.531, P = 0.025; d = 0.521, P = 0.028; d = 0.540, P = 0.034) and high (d = 0.888, P < 0.001) effect sizes. Compared with the CG, the SAS scores of the IG decreased, and the differences were statistically significant, with medium effect sizes (d = 0.793, PP < 0.001). The general linear model analysis showed that the SAS score of the IG from baseline to eight weeks after intervention was lower than that of the CG, with significant time effect differences (F = 4.411, P = 0.037). Table 3 Secondary outcomes by group at baseline and 8 weeks. Outcome Intervention(n = 37) Control (n = 37) Comparison between groups t/P-value Between-group effect size Cohen’s d Time × group interaction F/P-value Secondary outcomes Pulmonary function Forced Vital Capacity (FVC) Baseline 91.33 ± 17.55 87.03 ± 20.62 −1.411/0.158 8-week intervention 95.36 ± 21.75 # 85.49 ± 14.81 2.282/0.025* 0.531 0.806/0.371 Forced Expiratory Volume in 1 Second (FEV1) Baseline 69.58 ± 19.27 63.73 ± 22.18 −1.130/0.259 8-week intervention 78.81 ± 18.43 ## 68.29 ± 21.80 2.241/0.028* 0.521 0.480/0.489 FEV1/FVC Baseline 77.00 ± 18.53 76.97 ± 20.98 0.007/0.994 8-week intervention 85.84 ± 17.79 ## 74.32 ± 24.35 −2.124/0.034* 0.540 2.183/0.142 Maximal Voluntary Ventilation (MVV) Baseline 57.25 ± 17.10 52.45 ± 17.01 −1.270/0.204 8-week intervention 68.94 ± 13.80 ## 56.01 ± 15.31 3.819/<0.001** 0.888 2.416/0.122 Cervical range of motion Forward Flexion (FF) Baseline 40.87 ± 8.28 39.81 ± 7.15 0.589/0.558 8-week intervention 44.69 ± 10.98 # 41.51 ± 6.43 −2.184/0.029* 0.353 0.588/0.444 Backward Extension (BE) Baseline 34.77 ± 11.52 36.81 ± 12.63 −0.681/0.496 8-week intervention 36.84 ± 15.09 37.68 ± 14.66 −0.562/0.574 0.056 0.072/0.789 Left Lateral Flexion (LLF) Baseline 35.31 ± 6.13 33.62 ± 6.00 1.199/0.234 8-week intervention 37.00 ± 5.22 35.45 ± 4.73 1.341/0.184 0.312 0.006/0.939 Right Lateral Flexion (RLF) Baseline 35.92 ± 7.12 36.43 ± 4.92 −0.422/0.673 8-week intervention 37.05 ± 5.24 35.81 ± 5.22 −0.876/0.381 0.237 0.881/0.350 Left Rotation (LR) Baseline 60.27 ± 8.23 62.80 ± 6.06 −1.173/0.241 8-week intervention 64.87 ± 6.44 ## 62.62 ± 8.97 −0.908/0.364 0.289 3.742/0.055 Right Rotation (RR) Baseline 62.08 ± 6.37 63.59 ± 5.12 −1.130/0.262 8-week intervention 65.86 ± 8.71 # 62.97 ± 10.99 −0.919/0.358 0.292 2.730/0.101 Self-Rating Anxiety Scale (SAS) Baseline 39.65 ± 8.09 40.16 ± 6.80 −0.295/0.768 8-week intervention 32.76 ± 6.23 ## 38.28 ± 7.54 −3.306/<0.001** 0.793 4.411/0.037 # Significant differences from baseline (P < 0.05). ## Significant differences from baseline (P < 0.01). * Significant differences between groups (P < 0.05). ** Significant differences between groups (P < 0.01). Discussion The major purpose of this research was to evaluate the efficacy of cervical and thoracic “Daoyin” training compared with a control condition on pain, posture, pulmonary function, and emotional state in college students with the UCS. Our results revealed that the abnormal posture of the head forward and round shoulders, pain score, cervical spine function, pulmonary function, cervical range of motion, and emotional state improved after the cervical and thoracic “Daoyin” training, while no improvement was observed in the CG except for a decrease in FHA. Compared with the CG, the abnormal posture of the head forward and round shoulders, pain score, cervical spine function, respiratory function, cervical range of motion in FF and emotional state in the IG were statistically significant, with small, medium and high effect sizes. No adverse events occurred during the training, and all participants reported satisfaction with the exercise program. Cervical and thoracic “Daoyin” training on posture Exercise programs are gaining prominence as a viable way to improve head and shoulder alignments in individuals with UCS. For instance, Karimian et al.[ 25 ] implemented a customized program of exercise, designed to potentially affect forward head and rounded shoulder abnormalities. Seidi et al.[ 4 ] found that a comprehensive corrective exercise program could improve the alignment of men with UCS. Lastly, Kim et al.[ 26 ] reported that elastic band exercise programs could be effectively used in postural correction. Our results are in agreement with the above research findings. The training in our study, by comparison, has no limitations in terms of training ground and equipment. Standing or sitting position was chosen for training in our study, and participants were able to take training more easeful and convenient than in a prone position. Apart from the chair required to perform the "tiger lying" movement, our exercise did not require any other specific props and was easy to perform. After the rehabilitation therapist’s standardized teaching, college students can training in their spare time by their own. Cervical and thoracic “Daoyin” training on neck pain and active cervical range of motion It has been proposed that the abnormal head-forward posture influences the length–tension relation in cervical muscles, that may be the cause of neck pain[ 27 ]. Our results revealed that the cervical and thoracic “Daoyin” training had a positive effect on pain relief. The result is congruent with that reported by Yaghoubitajani et al[ 9 ]. In addition, the abnormal head-forward posture may restrict neck movement[ 28 ]. The "white goose stretching its neck" in our training program was discovered to enhance active cervical range of motion in FF by stretching and relaxing muscles. Cervical and thoracic “Daoyin” training on pulmonary function Due to the long-term abnormal posture of the head forward, round shoulder, and hunched back, the abdominal and chest cavity are closer to each other, resulting in a smaller thoracic volume and a decrease in the movement amplitude of active respiratory muscles during breathing[ 12 ]. Important auxiliary muscles of the respiratory system include the pectoralis minor and major, the scalenes, and the upper trapezius muscle. Long-term head-forward posture causes excessive activation of these muscles[ 11 ]. To remedy the decreased contraction of active respiratory muscles, the auxiliary respiratory muscles overcompensate, leading to impairment of the function of these muscles and a decrease in the volume of lung ventilation. To the best of our knowledge, less study has investigated the effects of exercise on lung function in UCS patients. Our results revealed that cervical and thoracic “Daoyin” training can improve postural abnormalities and coordinate respiratory muscle movements to address reduced lung function. When performing the "tiger lying" movement, the front of the chest is opened, which can effectively correct the round shoulder hunched back posture. Combined with “Dantian Gong,” the abnormal breathing mode of patients can be corrected with improved respiratory efficiency. Cervical and thoracic “Daoyin” training on emotional state The cervical and thoracic “Daoyin” training is a kind of Chinese traditional qigong, which is a movement of slow breathing in a calm state, self-adjustment, and exercise of the body's internal functions under the guidance of consciousness[ 29 ]. After the intervention of the cervical and thoracic “Daoyin” training, anxiety scores in UCS college students were found to decrease significantly. The findings are consistent with other studies demonstrating that the benefits of qigong exercise for reducing anxiety symptoms are substantial[ 30 , 31 ]. Strengths and limitations Strengths of the research include the rigorous randomized, parallel-controlled design, blinded assessment of outcomes, enhanced adherence to the intervention, and the high quality of trial control that requested trained "Daoyin" instructors to oversee the participants' training. Despite the promising results of our study, certain limitations should be addressed. We only evaluated short-term effects, and it is unclear whether the intervention effect is still present at eight weeks. The longer-term effects of similar interventions should be considered in future studies. The participant group included only college students and was concentrated in a single geographic area. Therefore, a more objective assessment of the group effects of cervical and thoracic exercise guidance training on UCS patients was not possible. To complete this, recruitment area should be increased to reduce the geographical effects. Correlational studies should include other groups in order to strengthen and extend the findings. This is an essential area for future study. Conclusion Based on our results, we conclude that eight weeks of cervical and thoracic “Daoyin” training can alleviate pain, enhance activities of daily living, improve the abnormal posture of leaning head forward and round shoulders, restore normal lung function, increase cervical range of motion in forward flexion and reduce anxiety symptoms in college students with UCS. Abbreviations UCS upper crossed syndrome IG intervention group CG control group FHA forward head angle FSA forward shoulder angle VAS Visual Analog Scale NDI Neck Disability Index FVC forced vital capacity FEV1 forced expiratory volume in 1 second MVV maximal voluntary ventilation FF forward flexion SAS Self-Rating Anxiety Scale Declarations Ethics approval and consent to participate The Ethical Review Committee of Biomedical Research, Fujian Medical University reviewed and gave its approval to the studies that used human subjects [(2023) Fuyi Ethics Review No. (102)]. All methods were performed in accordance with the requirements of this ethics. Written informed consent for this study was obtained from the participants themselves. Informed consent for publication statement We hereby confirm that all participants and their legal guardians (if applicable) have provided informed consent for the publication of potentially identifying information/images, including portraits, in this online open-access publication. Availability of data and materials The data have already been included in the manuscript and its attachments. If additional data is needed, it can be obtained by contacting the corresponding author. Competing interests The authors declare that they have no competing interests. Funding This study is funded by the National Natural Science Foundation of China (No.82374608) and Finance Department Project of Fujian Provincial (grant numbers 22SCZZX006). Author contributions GY, LJP, LM and YJ conceived and designed the trial. WYX, XCW, LXY and CYS conducted the trial. GY analyzed the data and write the manuscript. The submitted version of the paper was read, edited, and approved by all authors. 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Okuro RT, Morcillo AM, Ribeiro MA, Sakano E, Conti PB, Ribeiro JD. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. J BRAS PNEUMOL. 2011;37(4):471–9. Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J MANIP PHYSIOL THER. 2004;27(6):414–20. Esin OR, Khairullin IK, Shamsutdinova RF. [Upper crossed syndrome of muscle imbalance in adolescents with tension-type headache]. Zh Nevrol Psikhiatr Im S S Korsakova. 2019;119(9):12–6. Bae WS, Lee HO, Shin JW, Lee KC. The effect of middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises in upper crossed syndrome. J Phys Ther Sci. 2016;28(5):1636–9. Kang DY. Deep cervical flexor training with a pressure biofeedback unit is an effective method for maintaining neck mobility and muscular endurance in college students with forward head posture. J Phys Ther Sci. 2015;27(10):3207–10. Shan S, Ke C, Liu Y, Shi S, Quan R, Lou B. The effect of the combination of acupuncture and kinesiotherapy on upper cross syndrome based on mechanical balance principle – A randomized clinical trial. World J Acupunct - Moxibustion. 2022;32(03):185–92. Tang Q, Wang TT, Sun J. Study on rehabilitation of upper cross syndrome in teenagers with gentle exercise. Youth Sports. 2018(04):108–9. Huang Y, Zhai M, Zhou S, Jin Y, Wen L, Zhao Y, Han X. Influence of long-term participation in amateur sports on physical posture of teenagers. PEERJ. 2022;10:e14520. Yildiz TI, Turgut E, Duzgun I. Neck and Scapula-Focused Exercise Training on Patients With Nonspecific Neck Pain: A Randomized Controlled Trial. J SPORT REHABIL. 2018;27(5):403–12. MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, McAlpine C, Goldsmith CH. Measurement properties of the neck disability index: a systematic review. J ORTHOP SPORT PHYS. 2009;39(5):400–17. Cho J, Lee E, Lee S. Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: a randomized clinical trial. BMC MUSCULOSKEL DIS. 2017;18(1):525. Liao H, Luo Y, Long L, Peng J, Qiu X, Yuan P, Xu H, Jiang L. Anxiety and oral lichen planus. ORAL DIS. 2021;27(3):506–14. Karimian R, Rahnama N, Ghasemi G, Lenjannejadian S. Photogrammetric Analysis of Upper Cross Syndrome among Teachers and the Effects of National Academy of Sports Medicine Exercises with Ergonomic Intervention on the Syndrome. J RES HEALTH SCI. 2019;19(3):e450. Kim TW, An DI, Lee HY, Jeong HY, Kim DH, Sung YH. Effects of elastic band exercise on subjects with rounded shoulder posture and forward head posture. J Phys Ther Sci. 2016;28(6):1733–7. Fiebert I, Kistner F, Gissendanner C, DaSilva C. Text neck: An adverse postural phenomenon. WORK. 2021;69(4):1261–70. Ghamkhar L, Kahlaee AH. Is forward head posture relevant to cervical muscles performance and neck pain? A case-control study. BRAZ J PHYS THER. 2019;23(4):346–54. Matos LC, Machado JP, Monteiro FJ, Greten HJ. Perspectives, Measurability and Effects of Non-Contact Biofield-Based Practices: A Narrative Review of Quantitative Research. INT J ENV RES PUB HE. 2021; 18(12). Zhang XB, Zhang JL, Li MX, Yuan YP, Sun J. Baduanjin exercise can alleviate anxiety and depression of patients with COVID-19 in Square cabin hospital: A cross-sectional survey. Medicine. 2021;100(32):e26898. Li K, Walczak-Kozlowska T, Lipowski M, Li J, Krokosz D, Su Y, Yu H, Fan H. The effect of the Baduanjin exercise on COVID-19-related anxiety, psychological well-being and lower back pain of college students during the pandemic. BMC SPORTS SCI MED R. 2022;14(1):102. Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Li","suffix":""},{"id":308801439,"identity":"647ad9e6-eba5-4c0a-bcd6-9669e7ddba18","order_by":2,"name":"Chaowei Xie","email":"","orcid":"","institution":"Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chaowei","middleName":"","lastName":"Xie","suffix":""},{"id":308801440,"identity":"48e827d8-bd5e-4390-9fe5-3fbd29805d59","order_by":3,"name":"Xiaoyan Liu","email":"","orcid":"","institution":"Fujian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoyan","middleName":"","lastName":"Liu","suffix":""},{"id":308801441,"identity":"e52ac609-1de7-426c-8c6e-d05f9a621051","order_by":4,"name":"Yushan Chen","email":"","orcid":"","institution":"Fujian Medical 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University","correspondingAuthor":true,"prefix":"","firstName":"Jianping","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2024-04-30 12:47:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4349182/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4349182/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57872659,"identity":"8d361897-cf86-4d7f-84dc-052e297c7620","added_by":"auto","created_at":"2024-06-06 18:33:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":339800,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant flow diagram.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4349182/v1/8b43c9f8ca658fedd4b6e8b6.png"},{"id":57872661,"identity":"4e867792-fb67-44c1-8b2d-5fdeeb950b45","added_by":"auto","created_at":"2024-06-06 18:33:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1577956,"visible":true,"origin":"","legend":"\u003cp\u003eStatic neck and shoulder posture measurement diagram.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4349182/v1/19e7c678cf721ef51180b699.png"},{"id":57873758,"identity":"833ea3d3-6f72-49da-933c-a753e4b83f3e","added_by":"auto","created_at":"2024-06-06 18:41:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2620955,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4349182/v1/dc6c38ae-8e11-4827-828a-4e2e3c6869b9.pdf"},{"id":57872662,"identity":"b6806501-16f9-4c98-b269-c2517b3591ac","added_by":"auto","created_at":"2024-06-06 18:33:44","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":1606183,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4349182/v1/a55550672326af5c064cb67c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of the cervical and thoracic \"Daoyin\" training on posture and pulmonary function in patients with upper crossed syndrome: A randomized controlled trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the advent of the Internet, mobile phones and other electronic devices have become an integral component in everyone\u0026rsquo;s lives, especially students, whether it is to attend classes, make purchases, conduct transactions, or have social interactions[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The continuous use of these electronic devices can easily result in abnormal postures[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Neuromuscular imbalances can manifest as abnormal postures and can be related to some musculoskeletal conditions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Upper crossed syndrome (UCS), first identified by Dr. Vladimir Yanda(1979)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], is one of the most frequently cited complications with modern technological life, which is characterized by weakened middle and lower trapezius, scalenes, deep cervical flexors and serratus anterior at the same time as the rhomboids, as well as tightness in the upper trapezius, pectoralis minor and major and levator scapulae muscles[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It mainly leads to muscle imbalances, which eventually manifest in both tonic and phasic muscles[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The main causative factors include poor head and neck posture[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], abnormal breathing pattern, psychological problems of female adolescents, and unreasonable fitness methods[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePeople with UCS may display characteristics including forward head posture (FHP), round shoulders, elevated and prolonged shoulders and limited mobility of the cervical spine. These conditions are concomitantly related to neck and shoulder pain[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In UCS, pain is easily relapsing and long-lasting. The long-term effects of chronic pain on patients\u0026rsquo; mental health are profound, and UCS patients are prone to negative emotions such as anxiety, which may severely interfere with their quality of life[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFHP and rounded shoulders are abnormal postures that are typical of UCS patients. These conditions may lead to an increase in upper thoracic kyphosis, which can result in a decrease in the volume of the thoracic cage[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] as well as impede the motion of the diaphragm and other muscles of active respiration[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Abnormal postures typically lead to a reduction lung volumes and capacities, which in turn affects chest expansion and alveolar ventilation, resulting in a decrease in oxygen partial pressure and a reduction in exercise tolerance and respiratory efficiency.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo treat UCS patients, therapists have used a variety of approaches such as muscle energy techniques[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], kinesio taping[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], stretching exercises[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], pressure biofeedback[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and other techniques. While these approaches appear to work in clinical practice, they have a few limitations. The treatment must be carried out by a professional rehabilitation therapist to complete the operation, and the patient cannot do it alone. Moreover, the costs are prohibitive and may not be affordable for certain patients. In the context of traditional Chinese medicine, in addition to traditional therapies such as acupuncture[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], Chinese traditional exercise qigong was also found to play a positive role in restoring musculoskeletal balance in UCS patients[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nevertheless, these exercises are all based on the existing exercise guidance training, which are poorly targeted for patients with UCS.\u003c/p\u003e \u003cp\u003eOn the basis of traditional Chinese qigong, cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training emphasizes on training the neck and shoulder muscles of patients and correcting muscle imbalance and abnormal posture. In this study, we evaluate the effect of cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training on posture, pain, function, range of motion, pulmonary function, and emotional state in college students with UCS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA parallel-group randomized controlled trial was used in this study. The trial has been registered with the Chinese Clinical Trial Registry since June 20, 2023 (ChiCTR2300072669). It was also approved ethically by the Ethical Review Committee of Biomedical Research, Fujian Medical University [(2023) Fuyi Ethics Review No. (102)]. The Helsinki Declaration was followed in all aspects of the experiments. The study's reporting adhered to the rigor CONSORT guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe recruited 74 students of Fujian Medical University diagnosed with UCS. These students were recruited between Sep 1 and Oct 5, 2023, through posters published by the investigators. If a participant met the following requirements, they were eligible to participate.\u003c/p\u003e \u003cp\u003e(1) They were full-time college students of age 18\u0026ndash;26 years;\u003c/p\u003e \u003cp\u003e(2) Their condition satisfied the diagnostic criteria raised by Asian Fitness Society for UCS, i.e., (i) The corner of the eye and the upper corner of the ear are not in the same horizontal plane; (ii) The two earlobe lines are in front of the two acromion lines; (iii) The left and right acromiums are not equidistant from the midline of the human body. (iv) The distance between the scapula and the spinous process of the spine exceeds the width of the four fingers of the body finger; and (v) The cervical C7-posterior occipital carina curvature gap was larger than the four finger width of the body finger;\u003c/p\u003e \u003cp\u003e(3) They provided the informed consent.\u003c/p\u003e \u003cp\u003eWith regard to exclusion criteria, individuals were considered ineligible if they engaged in additional exercise in two weeks, which was likely to affect the results of the research. Individuals with a history of spine, shoulder fractures, surgery, or other diseases, or having severe cardia-cerebrovascular disease were also excluded.\u003c/p\u003e \u003cp\u003eDropout criteria were considered if three consecutive interventions were unsuccessful, the participant was unable to complete follow-up testing, or other factors were present that could influence the study results.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRandomization\u003c/h3\u003e\n\u003cp\u003eBlock randomization in a 1:1 ratio was generated using the SPSS 27.0 program, and allocation concealment was accomplished by opening sequentially numbered opaque sealed envelopes. The CG or the IG group to which the subject was randomly allocated was specified on a card inside. During the experiment, outcome assessors were kept unaware of the groups they were assigned to. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the flowchart for the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eAll the IG participants received instructions from two professional trainers to conduct the cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training. The time (Monday to Saturday at 5:00\u0026ndash;5:45 p.m. or 9:00\u0026ndash;9:45 p.m.) and location (a classroom of Fujian Medical University) of exercise were consistent and fixed. The training was conducted five times a week for two months.\u003c/p\u003e \u003cp\u003eThe cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training in this study consisted of the following five movements: (1) Dantian Gong (2) Turtle shrinking its neck (3) Roc spreading its wings (4) White goose stretching its neck (5) Tiger lying (Additional file 1). Supplemental Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e provides specifics on how cervical and thoracic \"Daoyin\" training works. The interval of each movement was 30\u0026ndash;60 s, and the duration was 45min.\u003c/p\u003e \u003cp\u003eThe CG participants were instructed to maintain daily activities and not partake in any further sports. Health education was given to all participants before the start of the experiment. The contents included UCS - related concepts, etiology, hazards, mitigation methods, and precautions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eAt baseline, the following demographic characteristics (age, weight, height, BMI) were assessed. Three researchers who were not involved in the group allocation process collected data and variables immediately prior to group allocation and following the intervention. Primary outcome measures included FHA and FSA, pain score, and cervical spine function assessment. Secondary outcome measures included pulmonary function test, cervical range of motion measurement, and emotional state assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eForward head and shoulder angles\u003c/h2\u003e \u003cp\u003eThe PA200LE body monitoring and analysis system (The Big Sports Co. Ltd, Japan) was used to evaluate the Forward Head Angle (FHA) and Forward Shoulder Angle (FSA). In a separate room, participants stood on the plantar platen with the camera positioned 2.4 m in front of the plate, and the camera's Red Cross was calibrated to coincide with the white cross on the plantar platen before evaluation began. During the postural assessment, participants wore tight fitting clothing and red marker points for photo image analysis were attached to the spinous process of the C-7 spinous, right tragus, and acromion. Participants stood with their feet 10 cm apart on the plantar platen in the side, with the fifth metatarsal eminence of their feet aligned with the white line in the sagittal direction of the plantar platen, looking forward with their hands naturally hanging at their sides. A straight line was made perpendicular to the ground through the C-7 spinous process, and then the tragus and acromion were connected with the C-7 spinous process respectively. \u0026ang;1 was FHA and \u0026ang;2 was FSA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) .The Angle Meter software was downloaded on the mobile phone, and the pictures were put into the software for analysis, the angles of FHA and FSA were calculated, and the final data were obtained[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePain score\u003c/h2\u003e \u003cp\u003eUsing the VAS, which consists of a 10 cm straight line, the degree of pain was assessed, with 0 on one end meaning \u0026ldquo;painless\u0026rdquo; and 10 on the other meaning \u0026ldquo;probably the most intense pain.\u0026rdquo; Patients marked their own pain on this straight line, with higher scores indicating more pain[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eCervical spine function assessment\u003c/h2\u003e \u003cp\u003eThe NDI was used to evaluate the cervical spine's functionality. It is a self-rated questionnaire, most commonly used in clinical studies related to neck pain. The evaluation took into account how neck discomfort affected a person's capacity to do activities of daily life[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The NDI scale consists of 10 items, each of which is scored from 0 to 5. More dysfunction is indicated by a higher score.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePulmonary function test\u003c/h2\u003e \u003cp\u003eBTL-08 Spiro (BTL, United Kingdom) was used to measure lung function. Calibration was performed before measurement, and the error was within 3%. At the same time, we ensured that the test was carried out in a relatively non-interference state. Before the test, 74 participants were uniformly trained on relevant test methods, and the formal test could only be started after they have mastered the correct test methods. The parameters of lung function test included forced vital capacity (FVC), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), and maximal voluntary ventilation (MVV) measured value as a percentage of estimated value (real/predicted). We tested each parameter thrice and took the mean value each time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCervical range of motion measurement\u003c/h2\u003e \u003cp\u003eThe active range of motion of the cervical spine was measured using a medical human joint protractor (BWP-JDC, China), which consisted of a fixed arm, a movable arm, and an axis[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Before measurement, the osseous markers of the cervical spine were required to be determined. The axis of the protractor was aligned with the joint axis. The fixed arm was parallel to the shaft of the proximal bone of the joint, and the movable arm was parallel to the shaft of the distal bone. Each of the six primary cervical spine movements was measured, including forward flexion (FF) and backward extension (BE) in coronal plane, left lateral flexion (LLF) and right lateral flexion (RLF) in sagittal plane, as well as left rotation (LR) and right rotation (RR) in transverse plane.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEmotional state assessment\u003c/h2\u003e \u003cp\u003eEmotional states were evaluated with the Self-Rating Anxiety Scale (SAS), a self-assessment tool for anxiety symptoms, which can reflect the subjective feelings of adults with anxiety tendencies. There are 20 questions in this scale, including 15 forward scores and five reverse scores. We multiplied the total assessed score by 1.25 to give the final score. Higher scores indicate higher anxiety[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSample size calculation\u003c/h2\u003e \u003cp\u003eBased on the results of an earlier study of upper crossed syndrome, the FSA was 44.60\u0026thinsp;\u0026plusmn;\u0026thinsp;7.54 and 38.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.81 degrees in the CG and the IG, respectively, at the end of the intervention. Using the GPower3.1 software, the trial required 74 participants (37 in each group) to be able to perform a statistical test with the assumption of a type I error of 5% (α\u0026thinsp;=\u0026thinsp;0.05), 95% power (β\u0026thinsp;=\u0026thinsp;0.05), and the allowance of a dropout rate of 10%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS 27.0 software. Means and standard deviations were used to describe results for continuous variables, while frequencies and percentages were used to provide results for categorical variables. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and P\u0026thinsp;\u0026lt;\u0026thinsp;0.01 were used to determine if results were statistically different and significantly different. The Shapiro - Wilk test test was used to determine if the data distribution was normal. Before and after the intra-group differences were compared by paired-sample t-test (normal distribution) and Wilcoxon rank sum test (skewed distribution). The independent-samples t-test (normal data distribution) and Mann\u0026ndash;Whitney U test (skewed distribution) were used to compare differences between groups. Cohen's d was used to calculate the between-group effect sizes, with effect sizes of 0.2, 0.5, and 0.8 regarded as small, medium, and large, respectively. The intervention effect between the CG and the IG group from baseline to 8-week post-intervention was analyzed by using the general linear model.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of participants\u003c/h2\u003e \u003cp\u003eAs stated earlier, total of 74 participants were recruited and allocated equally to either the CG or the IG. The trial was completed by all participants, and all were included in the analysis. Throughout the intervention period, no injuries or adverse events were seen or reported by participants.The baseline data were balanced and comparable, and no statistical differences were found between the two groups with regard to the proportion of sex, mean age, and BMI (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of participants at baseline.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et/χ2 value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (Male/Female, n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.05\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eDifferences between groups were not significant (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePrimary outcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the values for our primary outcomes. The values of FSA and FHA varied significantly between groups, with medium (d\u0026thinsp;=\u0026thinsp;0.579, P\u0026thinsp;=\u0026thinsp;0.008) and high (d\u0026thinsp;=\u0026thinsp;0.815, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) effect sizes in post-intervention measurements. FHA also decreased in the control group, and the difference was statistically significant after 8 weeks, indicating that the content of the health education had a positive effect. A significant difference was found in NDI and VAS values between the groups, with medium (d\u0026thinsp;=\u0026thinsp;0.754, P\u0026thinsp;=\u0026thinsp;0.005) and high (d\u0026thinsp;=\u0026thinsp;0.854, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) effect sizes in post-intervention measurements. Our general linear model analysis revealed that FHA and FSA were less in the IG compared with the CG from baseline to eight weeks after the intervention, with the significant group by time effect (F\u0026thinsp;=\u0026thinsp;11.415, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; F\u0026thinsp;=\u0026thinsp;5.490, P\u0026thinsp;\u0026lt;\u0026thinsp;0.020).\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\u003ePrimary outcomes by group at baseline and 8 weeks.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003cp\u003ebetween groups\u003c/p\u003e \u003cp\u003et/P-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween-group\u003c/p\u003e \u003cp\u003eeffect size\u003c/p\u003e \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime \u0026times; group\u003c/p\u003e \u003cp\u003einteraction\u003c/p\u003e \u003cp\u003eF/P-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003ePrimary outcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eForward Head Angle (FHA)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.15\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.245/0.217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.91\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;3.649/\u0026lt;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.415/\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForward Shoulder Angle (FSA)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.60\u0026thinsp;\u0026plusmn;\u0026thinsp;13.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.43\u0026thinsp;\u0026plusmn;\u0026thinsp;10.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.780/0.438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.53\u0026thinsp;\u0026plusmn;\u0026thinsp;13.41\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.83\u0026thinsp;\u0026plusmn;\u0026thinsp;11.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;2.649/0.008**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.490/0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisual Analogue Scale (VAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.088/0.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;3.313/\u0026lt;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.305/0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeck Disability Index (NDI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.130/0.896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.14\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;2.830/0.005**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.051/0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e# Significant differences from baseline (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e## Significant differences from baseline (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Significant differences between groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e** Significant differences between groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSecondary outcomes\u003c/h2\u003e \u003cp\u003eThe values for our secondary outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. After the eight-week intervention period, FF, FVC, FEV1, FEV1/FVC and MVV of the IG were significantly better than those of the CG, with small (d\u0026thinsp;=\u0026thinsp;0.353, P\u0026thinsp;=\u0026thinsp;0.029), medium (d\u0026thinsp;=\u0026thinsp;0.531, P\u0026thinsp;=\u0026thinsp;0.025; d\u0026thinsp;=\u0026thinsp;0.521, P\u0026thinsp;=\u0026thinsp;0.028; d\u0026thinsp;=\u0026thinsp;0.540, P\u0026thinsp;=\u0026thinsp;0.034) and high (d\u0026thinsp;=\u0026thinsp;0.888, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) effect sizes. Compared with the CG, the SAS scores of the IG decreased, and the differences were statistically significant, with medium effect sizes (d\u0026thinsp;=\u0026thinsp;0.793, PP\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The general linear model analysis showed that the SAS score of the IG from baseline to eight weeks after intervention was lower than that of the CG, with significant time effect differences (F\u0026thinsp;=\u0026thinsp;4.411, P\u0026thinsp;=\u0026thinsp;0.037).\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\u003eSecondary outcomes by group at baseline and 8 weeks.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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=\"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 \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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIntervention(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003cp\u003ebetween groups\u003c/p\u003e \u003cp\u003et/P-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eBetween-group\u003c/p\u003e \u003cp\u003eeffect size\u003c/p\u003e \u003cp\u003eCohen\u0026rsquo;s d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTime \u0026times; group\u003c/p\u003e \u003cp\u003einteraction\u003c/p\u003e \u003cp\u003eF/P-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eSecondary outcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003ePulmonary function\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForced Vital Capacity (FVC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.33\u0026thinsp;\u0026plusmn;\u0026thinsp;17.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e87.03\u0026thinsp;\u0026plusmn;\u0026thinsp;20.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026minus;1.411/0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.36\u0026thinsp;\u0026plusmn;\u0026thinsp;21.75\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e85.49\u0026thinsp;\u0026plusmn;\u0026thinsp;14.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.282/0.025*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.806/0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForced Expiratory Volume in 1 Second (FEV1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.58\u0026thinsp;\u0026plusmn;\u0026thinsp;19.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e63.73\u0026thinsp;\u0026plusmn;\u0026thinsp;22.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026minus;1.130/0.259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.81\u0026thinsp;\u0026plusmn;\u0026thinsp;18.43\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e68.29\u0026thinsp;\u0026plusmn;\u0026thinsp;21.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.241/0.028*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.480/0.489\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFEV1/FVC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e76.97\u0026thinsp;\u0026plusmn;\u0026thinsp;20.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.007/0.994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.84\u0026thinsp;\u0026plusmn;\u0026thinsp;17.79\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e74.32\u0026thinsp;\u0026plusmn;\u0026thinsp;24.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026minus;2.124/0.034*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e2.183/0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaximal Voluntary Ventilation (MVV)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.25\u0026thinsp;\u0026plusmn;\u0026thinsp;17.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e52.45\u0026thinsp;\u0026plusmn;\u0026thinsp;17.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026minus;1.270/0.204\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.94\u0026thinsp;\u0026plusmn;\u0026thinsp;13.80\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e56.01\u0026thinsp;\u0026plusmn;\u0026thinsp;15.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.819/\u0026lt;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e2.416/0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCervical range of motion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForward Flexion (FF)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.87\u0026thinsp;\u0026plusmn;\u0026thinsp;8.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e39.81\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.589/0.558\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.69\u0026thinsp;\u0026plusmn;\u0026thinsp;10.98\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e41.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;2.184/0.029*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.588/0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBackward Extension (BE)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.77\u0026thinsp;\u0026plusmn;\u0026thinsp;11.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e36.81\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.681/0.496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.84\u0026thinsp;\u0026plusmn;\u0026thinsp;15.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e37.68\u0026thinsp;\u0026plusmn;\u0026thinsp;14.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.562/0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.072/0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeft Lateral Flexion (LLF)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e33.62\u0026thinsp;\u0026plusmn;\u0026thinsp;6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.199/0.234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e35.45\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.341/0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.006/0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRight Lateral Flexion (RLF)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e35.92\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e36.43\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.422/0.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e37.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e35.81\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.876/0.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.881/0.350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeft Rotation (LR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e60.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e62.80\u0026thinsp;\u0026plusmn;\u0026thinsp;6.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;1.173/0.241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e64.87\u0026thinsp;\u0026plusmn;\u0026thinsp;6.44\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e62.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.908/0.364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.742/0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRight Rotation (RR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e62.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e63.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;1.130/0.262\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e65.86\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e62.97\u0026thinsp;\u0026plusmn;\u0026thinsp;10.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.919/0.358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.730/0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-Rating Anxiety Scale (SAS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e39.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e40.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;0.295/0.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8-week intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e32.76\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23\u003csup\u003e##\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e38.28\u0026thinsp;\u0026plusmn;\u0026thinsp;7.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;3.306/\u0026lt;0.001**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.411/0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e# Significant differences from baseline (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e## Significant differences from baseline (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e* Significant differences between groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e** Significant differences between groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe major purpose of this research was to evaluate the efficacy of cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training compared with a control condition on pain, posture, pulmonary function, and emotional state in college students with the UCS. Our results revealed that the abnormal posture of the head forward and round shoulders, pain score, cervical spine function, pulmonary function, cervical range of motion, and emotional state improved after the cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training, while no improvement was observed in the CG except for a decrease in FHA. Compared with the CG, the abnormal posture of the head forward and round shoulders, pain score, cervical spine function, respiratory function, cervical range of motion in FF and emotional state in the IG were statistically significant, with small, medium and high effect sizes. No adverse events occurred during the training, and all participants reported satisfaction with the exercise program.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training on posture\u003c/h2\u003e \u003cp\u003eExercise programs are gaining prominence as a viable way to improve head and shoulder alignments in individuals with UCS. For instance, Karimian et al.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] implemented a customized program of exercise, designed to potentially affect forward head and rounded shoulder abnormalities. Seidi et al.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] found that a comprehensive corrective exercise program could improve the alignment of men with UCS. Lastly, Kim et al.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] reported that elastic band exercise programs could be effectively used in postural correction. Our results are in agreement with the above research findings. The training in our study, by comparison, has no limitations in terms of training ground and equipment. Standing or sitting position was chosen for training in our study, and participants were able to take training more easeful and convenient than in a prone position. Apart from the chair required to perform the \"tiger lying\" movement, our exercise did not require any other specific props and was easy to perform. After the rehabilitation therapist\u0026rsquo;s standardized teaching, college students can training in their spare time by their own.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eCervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training on neck pain and active cervical range of motion\u003c/h2\u003e \u003cp\u003eIt has been proposed that the abnormal head-forward posture influences the length\u0026ndash;tension relation in cervical muscles, that may be the cause of neck pain[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our results revealed that the cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training had a positive effect on pain relief. The result is congruent with that reported by Yaghoubitajani et al[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, the abnormal head-forward posture may restrict neck movement[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The \"white goose stretching its neck\" in our training program was discovered to enhance active cervical range of motion in FF by stretching and relaxing muscles.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training on pulmonary function\u003c/h2\u003e \u003cp\u003eDue to the long-term abnormal posture of the head forward, round shoulder, and hunched back, the abdominal and chest cavity are closer to each other, resulting in a smaller thoracic volume and a decrease in the movement amplitude of active respiratory muscles during breathing[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Important auxiliary muscles of the respiratory system include the pectoralis minor and major, the scalenes, and the upper trapezius muscle. Long-term head-forward posture causes excessive activation of these muscles[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To remedy the decreased contraction of active respiratory muscles, the auxiliary respiratory muscles overcompensate, leading to impairment of the function of these muscles and a decrease in the volume of lung ventilation. To the best of our knowledge, less study has investigated the effects of exercise on lung function in UCS patients. Our results revealed that cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training can improve postural abnormalities and coordinate respiratory muscle movements to address reduced lung function. When performing the \"tiger lying\" movement, the front of the chest is opened, which can effectively correct the round shoulder hunched back posture. Combined with \u0026ldquo;Dantian Gong,\u0026rdquo; the abnormal breathing mode of patients can be corrected with improved respiratory efficiency.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training on emotional state\u003c/h2\u003e \u003cp\u003eThe cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training is a kind of Chinese traditional qigong, which is a movement of slow breathing in a calm state, self-adjustment, and exercise of the body's internal functions under the guidance of consciousness[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. After the intervention of the cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training, anxiety scores in UCS college students were found to decrease significantly. The findings are consistent with other studies demonstrating that the benefits of qigong exercise for reducing anxiety symptoms are substantial[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eStrengths of the research include the rigorous randomized, parallel-controlled design, blinded assessment of outcomes, enhanced adherence to the intervention, and the high quality of trial control that requested trained \"Daoyin\" instructors to oversee the participants' training.\u003c/p\u003e \u003cp\u003eDespite the promising results of our study, certain limitations should be addressed. We only evaluated short-term effects, and it is unclear whether the intervention effect is still present at eight weeks. The longer-term effects of similar interventions should be considered in future studies. The participant group included only college students and was concentrated in a single geographic area. Therefore, a more objective assessment of the group effects of cervical and thoracic exercise guidance training on UCS patients was not possible. To complete this, recruitment area should be increased to reduce the geographical effects. Correlational studies should include other groups in order to strengthen and extend the findings. This is an essential area for future study.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on our results, we conclude that eight weeks of cervical and thoracic \u0026ldquo;Daoyin\u0026rdquo; training can alleviate pain, enhance activities of daily living, improve the abnormal posture of leaning head forward and round shoulders, restore normal lung function, increase cervical range of motion in forward flexion and reduce anxiety symptoms in college students with UCS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUCS upper crossed syndrome\u003c/p\u003e\n\u003cp\u003eIG intervention group\u003c/p\u003e\n\u003cp\u003eCG control group\u003c/p\u003e\n\u003cp\u003eFHA forward head angle\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFSA forward shoulder angle\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS Visual Analog Scale\u003c/p\u003e\n\u003cp\u003eNDI Neck Disability Index\u003c/p\u003e\n\u003cp\u003eFVC forced vital capacity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFEV1 forced expiratory volume in 1 second\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMVV maximal voluntary ventilation\u003c/p\u003e\n\u003cp\u003eFF forward flexion\u003c/p\u003e\n\u003cp\u003eSAS Self-Rating Anxiety Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethical Review Committee of Biomedical Research, Fujian Medical University reviewed and gave its approval to the studies that used human subjects [(2023) Fuyi Ethics Review No. (102)].\u0026nbsp;All methods were performed in accordance with the requirements of this ethics. Written informed consent for this study was obtained from the participants themselves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent for publication statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hereby confirm that all participants and their legal guardians (if applicable) have provided informed consent for the publication of potentially identifying information/images, including portraits, in this online open-access publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data have already been included in the manuscript and its attachments. If additional data is needed, \u0026nbsp; it can be obtained by contacting the corresponding author.\u003c/p\u003e\n\u003ch4\u003eCompeting interests\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by the National Natural Science Foundation of China (No.82374608) and\u0026nbsp;Finance Department Project of Fujian Provincial\u0026nbsp;(grant numbers 22SCZZX006).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGY, LJP, LM and YJ conceived and designed the trial. WYX, XCW, LXY and CYS conducted the trial. GY analyzed the data and write the manuscript. The submitted version of the paper was read, edited, and approved by all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Home for Researchers editorial team (www.home-for-researchers.com) for language editing service.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTong WX, Li B, Han SS, Han YH, Meng SQ, Guo Q, Ke YZ, Zhang JY, Cui ZL, Ye YP et al. Current Status and Correlation of Physical Activity and Tendency to Problematic Mobile Phone Use in College Students. \u003cem\u003eINT J ENV RES PUB HE\u003c/em\u003e. 2022; 19(23).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArshadi R, Ghasemi GA, Samadi H. Effects of an 8-week selective corrective exercises program on electromyography activity of scapular and neck muscles in persons with upper crossed syndrome: Randomized controlled trial. PHYS THER SPORT. 2019;37:113\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo WG, Park SY. Effects of posture-related auditory cueing (PAC) program on muscles activities and kinematics of the neck and trunk during computer work. WORK. 2015;50(2):187\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise program improves alignment, muscle activation and movement pattern of men with upper crossed syndrome: randomized controlled trial. SCI REP-UK. 2020;10(1):20688.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillani SN, Ain Q, Rehman SU, Masood T. Effects of eccentric muscle energy technique versus static stretching exercises in the management of cervical dysfunction in upper cross syndrome: a randomized control trial. 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Chin Manipulation Rehabilitation Med. 2017;8(1):10\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaghoubitajani Z, Gheitasi M, Bayattork M, Andersen LL. Corrective exercises administered online vs at the workplace for pain and function in the office workers with upper crossed syndrome: randomized controlled trial. INT ARCH OCC ENV HEA. 2022;95(8):1703\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu F, Fang T, Zhou F, Zhao M, Chen M, You J, Jin Y, Xie J, Liu Z. Association of Depression/Anxiety Symptoms with Neck Pain: A Systematic Review and Meta-Analysis of Literature in China. \u003cem\u003ePAIN RES MANAG\u003c/em\u003e. 2018; 2018:3259431.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan J, Park S, Kim Y, Choi Y, Lyu H. Effects of forward head posture on forced vital capacity and respiratory muscles activity. J Phys Ther Sci. 2016;28(1):128\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin F, Parthasarathy S, Taylor SJ, Pucci D, Hendrix RW, Makhsous M. Effect of different sitting postures on lung capacity, expiratory flow, and lumbar lordosis. ARCH PHYS MED REHAB. 2006;87(4):504\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkuro RT, Morcillo AM, Ribeiro MA, Sakano E, Conti PB, Ribeiro JD. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children. J BRAS PNEUMOL. 2011;37(4):471\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J MANIP PHYSIOL THER. 2004;27(6):414\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsin OR, Khairullin IK, Shamsutdinova RF. [Upper crossed syndrome of muscle imbalance in adolescents with tension-type headache]. Zh Nevrol Psikhiatr Im S S Korsakova. 2019;119(9):12\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBae WS, Lee HO, Shin JW, Lee KC. The effect of middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises in upper crossed syndrome. J Phys Ther Sci. 2016;28(5):1636\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang DY. Deep cervical flexor training with a pressure biofeedback unit is an effective method for maintaining neck mobility and muscular endurance in college students with forward head posture. J Phys Ther Sci. 2015;27(10):3207\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShan S, Ke C, Liu Y, Shi S, Quan R, Lou B. The effect of the combination of acupuncture and kinesiotherapy on upper cross syndrome based on mechanical balance principle \u0026ndash; A randomized clinical trial. World J Acupunct - Moxibustion. 2022;32(03):185\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang Q, Wang TT, Sun J. Study on rehabilitation of upper cross syndrome in teenagers with gentle exercise. Youth Sports. 2018(04):108\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Y, Zhai M, Zhou S, Jin Y, Wen L, Zhao Y, Han X. Influence of long-term participation in amateur sports on physical posture of teenagers. PEERJ. 2022;10:e14520.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYildiz TI, Turgut E, Duzgun I. Neck and Scapula-Focused Exercise Training on Patients With Nonspecific Neck Pain: A Randomized Controlled Trial. J SPORT REHABIL. 2018;27(5):403\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, McAlpine C, Goldsmith CH. Measurement properties of the neck disability index: a systematic review. J ORTHOP SPORT PHYS. 2009;39(5):400\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho J, Lee E, Lee S. Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: a randomized clinical trial. BMC MUSCULOSKEL DIS. 2017;18(1):525.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao H, Luo Y, Long L, Peng J, Qiu X, Yuan P, Xu H, Jiang L. Anxiety and oral lichen planus. ORAL DIS. 2021;27(3):506\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarimian R, Rahnama N, Ghasemi G, Lenjannejadian S. Photogrammetric Analysis of Upper Cross Syndrome among Teachers and the Effects of National Academy of Sports Medicine Exercises with Ergonomic Intervention on the Syndrome. J RES HEALTH SCI. 2019;19(3):e450.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim TW, An DI, Lee HY, Jeong HY, Kim DH, Sung YH. Effects of elastic band exercise on subjects with rounded shoulder posture and forward head posture. J Phys Ther Sci. 2016;28(6):1733\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiebert I, Kistner F, Gissendanner C, DaSilva C. Text neck: An adverse postural phenomenon. WORK. 2021;69(4):1261\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhamkhar L, Kahlaee AH. Is forward head posture relevant to cervical muscles performance and neck pain? A case-control study. BRAZ J PHYS THER. 2019;23(4):346\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatos LC, Machado JP, Monteiro FJ, Greten HJ. Perspectives, Measurability and Effects of Non-Contact Biofield-Based Practices: A Narrative Review of Quantitative Research. INT J ENV RES PUB HE. 2021; 18(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang XB, Zhang JL, Li MX, Yuan YP, Sun J. Baduanjin exercise can alleviate anxiety and depression of patients with COVID-19 in Square cabin hospital: A cross-sectional survey. Medicine. 2021;100(32):e26898.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi K, Walczak-Kozlowska T, Lipowski M, Li J, Krokosz D, Su Y, Yu H, Fan H. The effect of the Baduanjin exercise on COVID-19-related anxiety, psychological well-being and lower back pain of college students during the pandemic. BMC SPORTS SCI MED R. 2022;14(1):102.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"College students, Exercise, Musculoskeletal diseases, Postural alignment, Lung function","lastPublishedDoi":"10.21203/rs.3.rs-4349182/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4349182/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eWith the growing ubiquity of electronic devices, the incidence of upper crossed syndrome (UCS) is increasing every year and tends to affect younger populations. The study designed to assess the effect of cervical and thoracic \"Daoyin\" training on pain, posture, pulmonary function, cervical range of motion, and emotional state in college students with UCS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a parallel-group randomized control study, assigning 74 college students to intervention group (IG) and control group (CG) at Fujian Medical University, Fujian, China. Instructed cervical and thoracic \"Daoyin\" training was given to students in the IG for eight weeks, five days a week for 45 minutes, whereas students in the CG continued with their usual activities. Primary outcomes, including forward head and shoulder angles, pain and cervical spine function, as well as secondary outcomes, such as pulmonary function, cervical range of motion and emotional state were measured at baseline and at a follow-up of eight weeks. These measurements were conducted using photogrammetry, visual analog scale(VAS), Neck Disability Index(NDI), pulmonary function, cervical range of motion test and Self-rating Anxiety Scale, respectively. We analyzed the effect of cervical and thoracic \"Daoyin\" training on college students with UCS using a general linear model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Analyses using general linear model revealed that the IG had a obvious improvement in the forward head angle, forward shoulder angle, and emotional state compared with the CG from baseline to eight weeks post-intervention (F=11.415, P\u0026lt;0.001; F=5.490, P=0.020; F=4.411, P=0.037). In addition, there were significant improvements in VAS (d=0.854, P\u0026lt;0.001), NDI (d=0.754, P=0.005), pulmonary function (forced vital capacity (FVC) (d=0.531, P=0.025), forced expiratory volume in 1 second (FEV1) (d=0.521, P=0.028), FEV1/FVC (d=0.540, P=0.034), maximal voluntary ventilation (MVV) (d=0.888, P\u0026lt;0.001) and cervical range of motion in forward flexion (FF) (d=0.353, P=0.029) at the end of 8-week intervention in IG. No side-effects were observed in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Cervical and thoracic “Daoyin” training can improve the pain, posture, cervical spine function, pulmonary function, cervical range of motion in forward flexion , and emotional state of college students with UCS to some extent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eChiCTR2300072669 (20/06/2023), Prospective registration, \u003ca href=\"http://www.chictr.org.cn/\"\u003ewww.chictr.org.cn\u003c/a\u003e\u003c/p\u003e","manuscriptTitle":"Effect of the cervical and thoracic \"Daoyin\" training on posture and pulmonary function in patients with upper crossed syndrome: A randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 18:33:39","doi":"10.21203/rs.3.rs-4349182/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T15:35:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-20T16:08:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309545700672556141339458331199259100595","date":"2024-09-15T16:54:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281816641774835923384059992825932906912","date":"2024-09-15T09:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31682329364301498501811062182193057781","date":"2024-09-13T05:50:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-19T20:13:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-07T22:14:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-05T18:08:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265252649951734606546459164479756486793","date":"2024-08-03T22:36:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36572550618962760894244117255065752247","date":"2024-08-01T21:07:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52388381251666366929104007081675456790","date":"2024-08-01T19:39:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-01T19:07:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T18:53:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-21T10:38:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-21T10:36:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2024-04-30T12:46:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4ceac539-e511-4099-bacb-27d7520c95bd","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 18:33:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4349182","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4349182","identity":"rs-4349182","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}