Effectiveness of Three Dimensional Approach of Schroth Method and Yoga on Pulmonary Function Test and Posture in Upper Crossed Syndrome With Neck Pain-A double blinded study

 

V. Rajalaxmi^1*, Jiby Paul², M. Nithya³, S. Chandra Lekha⁴, B. Likitha⁵

¹Vice Principal, Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute University, Velappanchavadi, Chennai - 600 077, Tamil Nadu, India.

^3,4,5BPT Student, Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute University, Velappanchavadi, Chennai-600 077, Tamil Nadu, India.

²Professor, Faculty of Physiotherapy, Dr. M.G.R. Educational and Research Institute University, Velappanchavadi, Chennai - 600 077, Tamil Nadu, India.

 

ABSTRACT:

Aim:  The aim of the study is  to find the efficacy of the Schroth Method and Yoga in improving the postural alignment and pulmonary function in subjects with upper cross syndrome.Background of the study:  In today’s population, the upper crossed syndrome is a highly prevalent one, among the people who work at desks and computers, laptops or who sit for a majority of the day and continuously exhibit poor posture.  It presents with a muscle imbalance between the tonic and phasic muscles and also interrupts the breathing pattern due to the involvement of accessory respiratory muscles. Due to the postural misalignment of head on trunk it is associated with pain in the neck and shoulder. When any attempts to correct this malaligned posture, towards an ideal posture using a combination of strengthening, stretching and feedback training in a three dimensional approach- Schroth method represent a significant component in improving the posture, mobility, balance and also corrective breathing. Methodology:   It is an experimental study comparing the Schroth Method and yoga in individuals with upper cross syndrome, conducted in ACS Medical College And Hospital for the duration of 3 months. The study included 30 subjects based on the inclusion criteria. Both male and female subjects between the age group 17-22 years with forward head posture, rounded shoulder, neck pain and those who were observed with abnormal pattern in Janda cervical flexion test, were included in the study.  Subjects with trauma, recent injury or surgery, any serious underlying pathology that influence the mobility of upper limb were excluded from the study.   The Janda flexion test and accurate posture assessment software, peak expiratory flow rate were used  in pre and post-test measurement. Result: Both the groups (A and B) showed significant difference in the post-test mean values, but group-A (schroth method) showed a better significant difference in post-test than group-B (yoga) at ***p<0.001.

 

 

 

 

 

 

INTRODUCTION:

In today’s population, the upper crossed syndrome is found to be a highly prevalent one among all the age group.  A study in the University of Lahore reports that 37.1% of students in the college presents with the upper crossed syndrome¹.  The upper crossed syndrome is a most common postural dysfunction in the musculature of the shoulder girdle /cerviothoracic region, which creates joint dysfunction, particularly at the atlanto-occipital joint, cerviothoraic joint C₄-C₅ segment, glenohumeral joint and T₄-T₅ segment².  It presents with over-facilitation, tightness, over-excitation of the  pectoralis major and minor, subclavius, upper trapezius, levator scapulae, sternocleidomastoid and sub occipital group whereas weakness, inhibition of the middle and lower trapezius rhomboids, serratus anterior,  longuscolli and capitis, infraspinatus, teres minor and thoracic paraspinals³. This syndrome mainly arises as a result of muscular imbalance that usually develops between tonic and phasic muscles, tonic muscle most of the time became tight leading to over-facilitated whereas phasic muscle are of lower activation resulting in inhibition^4,1.  People usually sit with position of the head with different manners which depend upon musculoskeletal structures, body changes regarding age, motor performances, cultural and occupation⁵. Because of the poor sitting posture, the patient may develop forward head posture along with rounded shoulder due to increased kyphosis in thoracic region and tension type head ache due to the stress on cervico-cranial region.  It is also characterized by altered scapular positions, muscular activities and body kinematics leads to gradual increase in muscle tension putting stress on neck and shoulder, results in pain, numbness, loss of function, restricted range of motion in the neck and different neuromuscular symptoms in the upper limb⁶.

 

Forward head posture is a head on trunk misalignment and is described as the excessive anterior positioning of the head in relation to a vertical reference line, increased lower cervical spine lordosis and rounded shoulder with thoracic kyphosis^7,8,9.  It is usually associated with shortening of the posterior cervical extensor muscles as well as shortening of the sternocleidomastoid results in hyperextension of the neck or increased cervical lordosis¹⁰. ThusDecreased mobility of thoracic spine and involvement of the accessory muscle of respiration results in respiratory dysfunctions.  Attempts to correct the posture using a combination of stretching, strengthening and feedback training represent a significant component of the physical therapy intervention as well as by the part of wellness program promoting general fitness like yoga¹¹. The schroth method helps the patients to halt curve progression, reverse abnormal curves, reduce pain, increases the vital capacity, and improves posture and appearance^12-16.   The schroth method consist of sensorimotor, postural and breathing exercises aimed at recalibration of normal postural alignment, static and dynamic postural control and spinal stability¹⁷.  Several studies of limited quality, demonstrated positive outcomes of schroth exercises on back muscles and breathing function¹⁸.  By using the sensorimotor feedback mechanism, the patients learn an individual correction in routine and corrected breathing pattern.  It is thought to promote the spinal correction progression, and to maintain the corrected posture in daily life activities.  Rotational angular breathing, an integrated component of schroth method plays a role in the selective contraction of the convex area of the trunk, and the inspired air directed to concave area of the thorax and enhances the mobilization of ribs¹⁹.  Yoga could be an optimal intervention for kyphotic posture in that it improves physical and emotional functioning as well as combat some underlying muscular and biomechanical causes²⁰.

 

MATERIALS AND METHODS:

Once the study is approved by the institutional review broad, a total of 30 subjects out of 45 volunteers were included in the study, based on the inclusion criteria.   The subjects were fully explained about the study and benefits of participating assuring confidentiality of their personal details, they were then asked to fill the consent form in acceptance with their participation in the study which is duly signed by the participant and the researcherGroup-A received the schroth three-dimensional exercise and the group-B received the yoga exercises.  In the pre-test measurement the subjects posture were assessed by the accurate postureassessment software posture pro8 mobile application which gives us the values of forward head shift and shoulder protraction, Janda cervical flexion test used to assess the pattern of movement, peak expiratory flow meter obtains themaximum expiration rate which indicates the pulmonary function

 

Maximum expiration rate which indicates the pulmonary function.  Materials such as the therapy balls, poles, bars, mat, rolling towels, and pillows are used in the study.

 

After the pre-test assessment, subjects in Group-A received the schroth method which 3-Dimensional exercise and Group-B intervened with yoga asanas. Both the groups performed one session per day for 6 days a week for 3 months.

 

All the relevant articles were analyzed and reviewed by the panel discussion of experienced physiotherapist. The panel met to discuss about this study and develop the intervention based on evidence. Generally schroth 3-D exercises are given only for the treatment scoliosis, in this study it is given for the UCS based on the principle of schroth exercise.

 

Schroth 3-D exercise: Group-A subjects received schroth 3-D exercise, Schroth corrective breathing-Rotational angular breathing, patient first assumes a posture in the cervico-cranial and shoulder girdle and the thoracic region are held in the correct posture.  The patient inspires air into the concave side and during the exhalation phase the isometric and isotonic muscle tensing occurs. While the patient is breathing, the therapist should observe the posture and movement of the thoracic cage and diaphragm. Basic posture correction in sitting, train the patient to attain the correct posture during the same by sensorimotor training in which the patients sit on the exercise ball with a correct head position and with retracted shoulder.  Schroth walking is a conscious walking, asks the patient to walk by stabilizing the head and thoracic region by arm leverage. Sensorimotor training: It is performed with the exercise ball in the three-dimensions, asked the patient to do thoracic extension against the ball, cervical exercise (quadruped position), cervical exercise in standing, cervical extension trapezius synergy. Posture re-alignment, includes the muscle cylinder exercise in side lying, kneeling and standing. Stretching the tightened structures: pectoralis, upper trapezius, arm flexors, levator scapulae.

 

Yoga Group-B subjects received yoga Asanas includes Bhujangasana, Dhanurasana, Virabhadrasana, Eka Pada Bhekasana, Pranayama, Salabhasana, Adho Mukha Shvanasana, and Matsyendrasana. These asanas involves the lengthening of the spinal cord, extension at the cervico-cranial, cervico-thoracic joint and mobilization of the upper limb, and thoracic cage and also a major role in improving the physical, mental and functional status.

 

Blinding:

The investigator assessing the outcomes remained blind to the patients allocation during the whole study period. Then the statistician who conducted outcome analyses was blinded to the group allocation by renaming the groups with numbers.

 

RESULT:

Statistical analysis is done using SPSS software version 16.0, on comparing the mean values of Group-A and Group-B on posture and pulmonary assessment shows significant reduction in the post test mean values of forward head shift (1.77), shoulder protraction (1.41), and improvement in peak expiratory flow rate (314). But Group-A, the schroth method shows postural alignment (forward head shift, shoulder protraction) were effectively improved than the Group-B and the peak expiratory flow rate were significantly improved in both the groups.  The Group-A shows better

 significant than Group-B at ***p<0.001.

 

 

 

 

Table -1  Comparison Of Pre and Post - test Mean Values Of Posture And Pulmonary Function In Group-A

GROUP - A	PRE TEST		POST TEST		t-TEST	SIGNIFICANCE
	MEAN	SD	MEAN	SD
FORWARD HEAD SHIFT	6.23	2.71	1.77	0.93	9.078	.000***
SHOULDER PROTRACTION	5.36	1.77	1.41	0.83	12.149	.000***
PEFR	176	16.35	314	20.63	27.153	.000***

 

 

 

 

Table -2 Comparison Of Pre and Post – test Mean Values Of Posture And  Pulmonary Function In Group-B

GROUP – B	PRE TEST		POST TEST		t-TEST	SIGNIFICANCE
	MEAN	SD	MEAN	SD
FORWARD HEAD SHIFT	6.22	2.71	3.70	1.33	9.496	.000***
SHOULDER PROTRACTION	5.34	1.94	2.80	0.74	10.787	.000***
PEFR	171	15.59	315	20.99	27.339	.000***

 

 

 

Table -3  Comparison Of Pre and Post-test mean and standard deviation Values Between Group-A  And Group-B

POSTURE AND PULMONARY MEASURES		PRE-TEST			POST-TEST			SIGNIFICANCE
		MEAN	SD	t-Test	MEAN	SD	t-TEST
FORWARD HEAD SHIFT	GROUP- A	6.23	2.71	9.078	1.77	0.92	9.078	.000***
	GROUP-B	6.22	2.71	9.496	3.70	1.33	9.496	.473*
SHOULDER PROTRACTION	GROUP-A	2.20	1.33	9.496	1.41	0.83	12.149	.000***
	GROUP-B	5.34	1.94	10.78	2.80	0.74	10.78	.492*
PEFR	GROUP-A	176	16.35	27.153	314	20.63	27.15	.000***
	GROUP-B	171	15.59	27.33	315	20.99	27.33	.000***

 

 

CONCLUSION:

The result of this study reveals that there is a significant difference in the post-values of both the two group in subjects with upper cross syndrome.  Both the groups (schroth method and yoga) shows improvement in the postural alignment (forward head shift, shoulder protraction) and pulmonary function.  The study concluded that the postural alignment achieved from schroth method is better than that achieved by yoga.  Group-B also shows significant reduction in post  test values but Group-A shows lower mean values in the post-test than Group-B.  But the pulmonary function is significantly improved in both the groups in the post test mean values.

 

DISCUSSION:

The present study was conducted with the sample size of 30 subjects (15 males and 15 females) to compare and find out the effectiveness of schroth method (A three dimensional approach) and yoga in subject with upper crossed syndrome.  Schroth technique positively influenced the Cobb angle, vital capacity, strength and postural defects in outpatient adolescents²¹. Jull et al. found that patients with neck pain put higher demands on their superficial neck muscles than do healthy people, to compensate for weakness of   the   deep muscles²².  Lehnert-schroth reported a case report in which the patient referred to physical therapy due to her complaints of scapula and hip pain, which interfered with her sleep patterns as well as daily activities.  After the utilization of postural exercises described by the schroth method, her complaints of pain were elimination.  Although increasing her vital capacity was not a reason she stated for attending physical therapy, increase in vital capacity of 750ml was noted at the post-test measurement and also documented that 85% reduction in pain²³.  The   role   of   deep   muscles   for   maintenance of cervical posture was verified in a computer model, which showed the regions of local segmental instability if only the large   superficial muscles of the neck were stimulated to produce movement, particularly in an ideal posture²⁴.  Weiss noted that there is an increase in vital capacity of about 250ml in adults with scoliosis due to the schroth method²⁵.  Specific postural re-education exercise, initiated with the formation of a neutral lumbopelvic posture, should therefore be viewed at this time as a component of rehabilitation, providing a simple means for the patient to recruit the deep postural muscles of the cervical spine in a functional way regularly throughout the day²⁶.  In this study, the schroth method is intervened for upper crossed syndrome and it was noticed that the postural alignment measure s-forward head shift, shoulder protraction and peak expiratory flow rate (PEFR) showed improvement in both the groups, Group-A – Schroth method and Group B – Yoga asanas.  When the intra groups (SPSS) means values of forward head shift, shoulder protraction and PEFR was analyzed.  Group -A shows post-test mean forward head shift (1.77), shoulder protraction (1.41) and PEFR (314).  Group B shows post-test mean forward head shift (3.70), shoulder protraction (2.80) and PEFR (315) values clearly indicated that there was statistically significant improvement in reducing forward head shift, shoulder protraction and PEFR in two groups.  Group-A shows lower mean values in post test than Group B.  The Group-A schroth method found to be presenting with lower post-test mean values than the Group-B.

 

The study concluded that the Yoga is more effective than the Pilates and Tai chi and Control Group exercise for chronic mechanical neck pain while Pilates,Tai chi and control Group exercise even showed a considerable decrease in symptoms when comparing the post-test mean values²⁷.

 

AUTHORS CONTRIBUTION:

All authors have contributed equally.

 

ACKNOWLEDGEMENT:

I would like to thank the authorities of Dr. MGR Educational and Research Institute, University and the Principal Faculty of Physiotherapy for providing me with facilities required to conduct the study.

 

ETHICAL CONSIDERATIONS:

The manuscript is approved by the Institutional Review board of faculty of physiotherapy. All the procedures were performed in accordance with the ethical standards of the responsible ethics committee of both (Institutional and national) on human experimentation and the Helsinki Declaration of 1964 (as revised in 2008).

 

CONFLICT OF INTEREST:

All contributing authors declare that they have no Conflicts of interest. This study was approved by Institutional Review Board of Physiotherapy, Dr. MGR Educational and Research Institute University, Chennai.

 

FUNDING:

This is a self-funded study.

              

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Accepted on 24.04.2018          © RJPT All right reserved

Research J. Pharm. and Tech 2018; 11(5):1835-1839.