The study was the randomized control trial with trial registered number CTRI/2016/08/007140 (www.ctri.nic.in). After the ethical concern was received from the Institutional based Ethical Committee from doctoral Committee, the study was conducted from August 2016 to January 2017 in Orthopaedic outpatient, Physiotherapy Department of Mohamed Sathak AJ College of Physiotherapy, Tamil Nadu, India. The sample size was calculated from the pilot study done among the subjects with upper body dysfunction interpreted results. Sixty subjects with upper body dysfunction of both genders between 25-55 years were included in this study. The effects of poor posture might be cumulative and therefore might increase in severity after the age of 35 years (Russek AS) [10].

The subjects with any neurological problems like disc prolapse and stroke, any recent surgery and recent fracture or tumour around shoulder, neck and upper back region are excluded from the study. After explaining the procedure and benefits; informed consent was taken from the participating subject [Table/Fig-1].

[Table/Fig-1]:

Consort algorithm for subject allocation and data analysis of randomized, controlled trial.

Allocation of subjects into two groups was done by simple random numbering method. In subjects with upper body dysfunction, the kinematic alteration of shoulder, neck and upper back region will leads to postural adaptation. Later the muscle imbalance occurs because of these adaptations as stated by Janda’s approach of upper cross syndrome. Thus, we have framed the corrective exercise strategy with scapular stabilisation, deep cervical flexors endurance [Table/Fig-2] versus conventional exercise in control group [Table/Fig-3]. Thirty subjects in Group-A receives the corrective exercise strategy in two phases (In Phase-I starts with two weeks of warm-up exercise, passive stretching to upper trapezius, levator scapulae, sternocleido mastoid, pectoralis major and minor, lattismus dorsi, posterior capsule stretch, thoracic mobilization (using foam roller), isolated activation to middle and lower trapezius, rhomboids, serratus anterior, deep cervical flexors endurance training for four days/week with 15 reps/set of three sets, 40 min/day.

In phase-II, the gradual strengthening exercises for underactive muscles and reactive integration training for six weeks of total duration, four days/week with 15 reps/set of three sets, 40 min/day). 30 subjects in Group-B received the conventional exercise Free exercise to shoulder joint, pendular exercise for shoulder, active stretching of pectoralis minor and major muscles, isometrics exercise to neck and scapula, shoulder blade squeezing exercise, shoulder shrugging exercise, shoulder wall sliding exercise, relaxed breathing exercise for eight weeks of duration with 40 min/day, (15 reps/set) three sets and four days/week [11]. The high-intensity strength training with several different neck/shoulder exercises targeting the deltoids, upper trapezius, neck extensors etc. reported pain reductions corresponding to approximately 1–3 on a 10-point scale [11]. In scapular stabilisation exercise, the subject was prone lying and arm is moved upward in 90° and 120° of shoulder abducted position. Postural deviation of upper body dysfunction (forward headed posture, flat neck, shoulder protracted or retracted, kyphosis) can be assessed using posture software which will give the cumulative values of changes as posture number either in minus or plus value. Pre and post posture analysis were analysed using posture pro 8 software, where the subjects were requested to stand in a erect standing posture and the sagittal plane images were taken with the camera at 1.5 m distance from subjects and these photogrammetric images were incorporated in posture pro 8 software using window 10. In this software, the subjects image were uploaded and the posture number value is achieved by clicking on the subjects ear lobe, shoulder tip and greater trochanter of hip joint [Table/Fig-4] along with flexibility of pectoralis minor were assessed using ruler scale method, where the subjects are positioned in supine lying and the measurement of linear distance from the treatment table to posterior aspect of acromion process with average of three measurements were taken. This method of measuring the pectoralis minor muscle length testing have been proved by intra-reliability study in subjects with and without signs of shoulder symptoms by Lewis JS and Valentine RE 2007 [12].

[Table/Fig-4]:

Postural evaluation of subjects using postural analysis software.

The data analysis was performed using SPSS statistical package for Social Science in Microsoft windows. The data were normally distributed and therefore parametric tests were performed. Descriptive statistics were presented as numbers and percentages. The data were expressed as Mean and SD. Independent sample student t-test/Mann-Whitney U test were used to compare continuous variables between two groups. Paired sample test/ Wilcoxon signed rank were used for ordinal data into within groups. A two sided p-value <0.05 was considered statistically significant.

The baseline anthropometric data of subjects are presented in [Table/Fig-5]. After interpretation of data, both the group showed the postural alteration [Table/Fig-6] and pectoralis minor muscle length [Table/Fig-7] changes. A p-value (<0.001) of both group showed highly significant changes. But comparing the both groups the subjects who received the corrective exercise strategy shown more percentage of improvement in posture alteration (56.25%), pectoralis minor muscle length changes (68.69%) than the conventional exercise received subjects in posture alteration (24.86%) and pectoralis minor muscle length changes (21.9%).

Postural education and assessments are a part of physical therapy education and clinical practice. The normal upright posture has been described as a state of balance requiring minimal muscular effort to maintain [13]. As kyphosis increases, there are certain alterations in the normal alignment that may cause pain and risk of dysfunction in the shoulder and pelvic girdle, and cervical, thoracic, and lumbar spine. Forward head posture, scapula protraction, reduced lumbar lordosis, and decreased standing height are often associated with hyperkyphosis [14]. The consequence of postural abnormalities can leads to pain and injury, postural education and correction have been used as treatment approaches [15,16]. Many study literature have shown a reasonable correlation between radiographic measurements and the placement of markers for measuring the abnormal posture and these method of the anatomical landmarks measuring postural abnormalities creates a possible use of photography as a form of scientific assessment (do Rosário JC 2013) [17]. Furlanetto TS et al., states that the photogrammetric method of evaluating the spine is a viable, valid and reproducible but still need more study literature [18]. Postural assessment through photography is a simple method that allows the acquisition of quantitative values to define the alignment of body segments [16]. The photographs provide valid and reliable indicators of the position of the underlying spine in sitting and the results of this study by Niekerk SM et al., the photograph Method can be used in practice as a valid measure of sitting posture [19]. In our previous case report study, we used to evaluate the upper body dysfunction of 94-year-old male subjects using posture pro 8 software and the significant percentage of kyphotic deviation changes occurs after the intervention [20].

The upper body dysfunction is defined as a muscular imbalance of upper part of the body which includes the chest, shoulders and neck musculature. The certain muscle group become tight and overactive, in turn the opposing muscles which are the mid and lower trapezius muscles (back musculature), serrates anterior (scapular stabilising muscles) and deep neck flexors become under-active and weak [21]. As this muscular imbalance persist for longer period, the subjects with upper body dysfunction become overloaded from their daily activities and will usually adapt to the activities they do the most, which results in the ‘tonic’ muscles becoming overactive, tight and adaptively shortening while the ‘phasic’ muscles becoming under-active, weak. These adaptive changes creates a poor posture around the neck, shoulder and upper back region which can be assessed by posture pro software analysis method. The protracted shoulder is associated with shorter pectoralis minor muscle [22]. Muscular imbalance can be corrected by strengthening of the posterior scapular stabilizers combined with stretching of the pectoral muscles can correct posture and maintain normal scapula-humeral rhythm [23]. The exercise is progressed in sitting and standing with resistance gradually [11]. The deep cervical endurance can be trained using the biofeedback unit initially in supine lying and progressed in sitting and standing [24].

In this study, the corrective exercise strategy includes the overactive tonic muscles have been passively stretched and the under-active phasic muscle have been strengthened in a progressive grades which is compared with the conventional exercise like isometric exercise and active free exercise. Interpretation of both the groups showed good progression in posture changes but more significant changes in the corrective exercise strategy group.

Scapular stabilisation exercise, deep cervical flexor endurance training, pectoralis minor and major muscle stretching, thoracic mobility exercise, breathing exercise and postural education were performed four times a week for eight weeks showed significant changes in the posture deviation and the pectoralis minor muscle length test. The software used to evaluate the postural changes before and after the interventions showed much differences which is correlated with the changes in the pectoralis minor muscle length flexibility. From this study, we conclude that the posture analysis software can be more viable and reproducible tool of evaluating the subjects with upper body dysfunction.