The Effect of Eight-Week Water-Based Corrective Exercises on Forward Head, Rounded Shoulder, Thoracic Hyperkyphosis Posture, and Neck Pain: A Randomized Controlled Trial

Background: The lifestyle and long-term use of communication technologies have led to the prevalence of neck pain and concurrent forward head posture (FHP), Rounded shoulder posture (RSP), and hyperkyphosis (HK) deformities. The present study aimed to determine the effects of the eight-week water–based corrective exercises on FHP, RSP, HK deformities, and neck pain. Methods: After screening the 200 students, 30 students with FHP, RSP and HK were selected. They were assigned randomly to experimental (n=14) and control (n=16) groups. Imaging from lateral view and AutoCAD software were used to evaluate the FHP and RSP angles and HK was measured by flexible ruler. Moreover, Visual Analog Scale (VAS) was used to assess shoulder, and neck pain. These variables were assessed before and after 8-week intervention period. Results: statistical analysis indicated a significant group by time interaction in the FHP (P=0.001), RSP (P=0.001), HK (P=0.001) angels and in terms of the pain (P=0.001) which indicated a decrease in kyphosis and forward head angels, and Rounded shoulder displacement. But no significant decrease was observed in control group measures (all P>0.05). Conclusions: Based on the results, probably performing 8-week corrective exercises in the water environment could have more effect on FHP, RSP, HK angels decreasing and neck and shoulder pain reduction. This corrective exercises protocol can be suggested to professionals in order to correct these concurrent malalignments.

4 these deformities are linked conditions [3,[19][20][21]. Some other studies used therapeutic regimens, such as physiotherapy combined with corrective exercises, but their results cannot be attributed to the corrections alone [22]. A more effective approach is for a therapist to prescribe integrated corrective interventions for the aforementioned deformities. Specialists should also look into the potential advantages presented by the water-based correction of such deformities.
Given the lack of investigations into rehabilitative physical activities performed in water for concurrent deformities in the upper extremity, the present study examined the benefits of these interventions to uncover strategies for correcting such deformities. The researchers have hypothesized that implementing corrective exercises in a water environment can serve as effective rehabilitation for people suffering from FHP, RSP, HK, and neck pain.

Study design
We conducted an assessor-blinded, parallel-group (1:1 allocation ratio) randomized controlled trial. Data were collected at the Sport Rehabilitation Laboratory. The study's protocols were approved by the research ethics committee of the Medical Sciences (Registration no.: IR.UMSHA.REC.1395.470). The protocols were also registered (Registration no.: IRCT20170615034554N2). The subjects provided informed consent forms.

Participants
Community participants were recruited between Jun 2018 and October 2018. They were screened using the posture assessment grid. RSP and FHP were defined as the anterior displacement of the middle point between the anterior borders of the 5 acromion and tragus in relation to a vertical reference line, and HK was defined as the posterior displacement of the middle point between the thoracic curve apex in relation to a vertical reference line [23]. The inclusion criteria were an FHP >46 degrees; an RSP >52 degrees [24] and kyphosis >42 degrees [25]; pain in the head and neck, shoulder, and spine during laptop or cellphone use; and an age range of 18 to 22 years old [26]. The exclusion criteria were a history of elite exercise; membership in professional sports clubs; a history of fractures, surgery, or joint diseases, especially in the spine, shoulder girdle, and pelvis; skeletal malalignment in the ankle and knee; visual impairment irreparable through glasses; vestibular system impairment; obesity, water allergy, respiratory problems, or cardiovascular disease; and a history of migraines and analgesic usage. The screening identified 34 eligible subjects with concurrent deformities (Fig. 1). G*Power 3.1 software [27], a testing power of 0.85, an effect size of 0.8, and a significance level of 0.05 were used to estimate the minimum sample size, which, for this study, was 12 [27,28].
Allowing for the possibility of dropouts, we selected all the 34 individuals and divided them randomly into experimental (17 males) and control (17 males) groups (Table 1). Out of this sample, four withdrew from participation for various reasons, leaving us with a final sample of 30 (14 in the experimental group and 16 in the control group).

Randomization and Masking
The subjects were randomized using the Random Number Generator, after which they were assigned to experimental and control groups on the basis of allocation concealment via the sequentially numbered, opaque sealed envelopes method by an uninvolved person and stored in a locked location. Another independent person 6 opened the next sequential envelope and informed the therapist of treatment allocation by phone . The assessor was unaware of the exercises and interventions   prescribed for the groups, but blinding could not be imposed on the subjects and   the statistician with respect to the correctional training and the grouping and their assigned exercises, respectively.

Water-Based Corrective Exercises
Previous research recommended treatment to be performed in three stages: the normalization of peripheral structures (inhibition), the restoration of muscle balance (elongation and activation), and the facilitation of afferent system and sensory motor training (integration) [3]. In the present study, the exercises involved over the course of these steps were carried out in a water environment. In the first stage, trigger points were released through massage in water, and the myofascial release of stiff muscles was induced using a foam roller. In the second stage, static stretching exercises were implemented to relieve muscle tightness. Given the tightness in respiratory accessory muscles owing to concurrent deformities, muscle stretching was combined with corrective exercises related to breathing patterns.
Then, strengthening exercises (activation) were performed. Finally, proprioceptive exercises were conducted for neck and shoulder joints. Because the last stage of the interventions was functional (integrative) in nature, the subjects were asked to participate in a game in water while assuming correct posture. The eight-week training program involved three sessions per week, which comprised warm-up exercises (10-15 minutes), water-based corrective exercises (35-45 minutes), and cool down activities (5-10 minutes) (Appendix 1).

FHP and RSP Postural Assessment
Imaging, which has been used in numerous studies, has been found to exhibit good reliability [16, 24 and 29]. In the current work, lateral view images were used to evaluate FHP and RSP angles. Three anatomical landmarks (the tragus, C7, and the acromion) were marked (Fig. 2), and a digital camera (Sony Cyber-shot DSC-RX100VI, Japan) mounted on a tripod was placed at a distance of 265 cm from the wall, aligned with the shoulder of a subject. He was then asked to stand in a position with which he was completely comfortable and directed to look at the point (a cross) on the wall (eyes along the horizon). After five seconds, the examiner took three images from the lateral view [16] and inputted them into a computer.
AutoCAD 2013 was used to measure the angle of the perpendicular line connecting the tragus to C7 (FHP angle) and the angle between the perpendicular line running from the acromion process to C7 (RSP angle). The means of three angles obtained for each deformity were recorded as the desired angles for FHP and RSP (Fig. 2) [16,24].

Measurement of Thoracic Kyphosis Angle
Different studies showed that a flexible ruler has better sensitivity and validity (r = 0.72) than that exhibited by a radiograph [30,31]. Accordingly, the present research employed a flexible ruler (24-inch Staedtler Mars, Nurnberg, Germany) in measuring thoracic kyphosis angles. Before measurement was initiated, the T2 and T12 vertebrae were marked. First, the T2 vertebra was identified by asking a subject to flex his head forward, at which position the spinous processes of the C6 and C7 vertebrae could be visibly recognized. The examiner placed two index and middle fingers on these segments, and as the subject returned to a normal posture. 8 The remaining spinous process was thus indicated as relating to C7. Counting was subsequently initiated from the spinous process of C7 downward to determine the location of the T2 vertebra. Second, to identify the spinous process of T12, the examiner touched the lower edge of the 12th rib on two sides using his thumb and then simultaneously moved two fingers on both sides of the body upwards and inwards until the rib disappeared. The distance between the two fingers was connected, and the middle point was marked as the spinous process of T12 [32].
The ruler was placed on T2 and T12 and placed entirely on the spine by hand. The curvature was drawn on A3 paper, and the kyphosis angle was measured using equation (1) (Fig. 3) [33]. The ICC of the flexible ruler was 0.92 [34].
[Due to technical limitations, the formula could not be displayed here. Please see the supplementary files section to access the formula.]

Assessment of Neck and Shoulder Pain
The intensity of neck and shoulder pain was assessed using a 10 cm visual analog scale (VAS), which presents good reliability and validity (intraclass correlation = 0.92) [35]. Along this scale, 0 indicates the absence of pain, 1 denotes minimal pain, and 10 is equivalent to intolerable pain. The participants were asked about the severity of pain that they experience during daily activities, when they use a mobile phone or laptop for a long time, and when they study for long periods. The intensity of subjective pain was measured before, during, and after the interventions.

Statistical Analysis
The Shapiro-Wilks test and Levene's test were carried out to assess the normal distribution of data and the homogeneity of variances. An independent sample t-test was performed to evaluate intergroup differences before the interventions.
Repeated measures ANOVA with a 2 × 2 (group × time) mixed design was used to analyze intergroup changes over time. Cohen's d was adopted in calculating effect size in the pre-and post-test comparison. Values of 0.01, 0.06, and 0.14 were regarded as corresponding to small, moderate, and considerable effects, respectively [36]. The data were analyzed using the SPSS software (version 20), and a P value of 0.05 was considered statistically significant.

Results
Data distribution in the two groups was normal (P>0.05), and variances were homogeneous (P> 0.05). The results of the comparison of demographic characteristics and HK, RSP, and FHP angles in the pre-test for the experimental and control groups are presented in Table 1. The independent sample t-test showed that these elements did not significantly differ between the groups in the pre-test (all P>0.05). Rounded shoulder angle than that measured for the control participants (Table 3).
No significant decrease in RSP was observed in the control group (P > 0.05) (Fig. 4).
The results of the repeated measures ANOVA showed significant group-by-time interactions with regard to changes in VAS [F (1,28) =187.8, P=0.001, effect size=0.8], and the post-hoc analysis reflected a significant decrease in neck and shoulder pain (P=0.001, effect size=0.96) among the exercise participants. A significant difference was found between the experimental and control groups at the post-test (P=0.001), during which the former group presented with less severe neck and shoulder pain than that experienced by the control group (Table 2).  4. Discussion 11 The results showed that the water-based corrective exercises significantly decreased postural deformities and neck and shoulder pain among the male students. The large effect size (0.9) confirmed that the interventions effectively corrected the postural deformities and relieved pain in the upper extremities. Sahrmann (2011), belived that exercises intended to correct movement and malalignment result in appropriate neuromuscular and musculoskeletal adaptations [20]. She also considered the most important stage of correction to be the training of individuals on maintaining proper alignment when they accomplish repetitive tasks and assume certain postures for prolonged durations [2]. Correspondingly, the first session of the corrective exercise protocols implemented in the current work revolved around training the participants on maintaining alignment in their activities.
In this research, the significant correction of concurrent deformities and muscle imbalances that occurred in relation to FHP, RSP, and HK can be attributed to two factors: the properties of water environments and the protocols for corrective exercises. Performing corrective exercises in water seemed to be one of the determinants of interventional effectiveness in this study. The turbulence effect from water during movement appeared to clear the way for different proprioception and sensory responses-patterns that are not induced by land-based exercises [37].
An alternative explanation is that the warmth and hydrostatic pressure of water increase blood flow, inhibit pain receptors, and stimulate trigger points, thereby enabling correction and eliminating muscle tightness [38]. The warmth of water can also be beneficial in restoring the flexibility of muscles and the range of motion of joints through muscular expansion and relaxation [38]. Although no previous study explored water-based corrective exercises for postural deformities, certain evidence supports our findings. Kamioka, for example, reported that aquatic exercises exert small but statistically significant effects on pain relief and related outcome measures for locomotor diseases [39]. Neira additionally affirmed the effectiveness of aquatic therapy for balance and pain in women with fibromyalgia [37].
The significant correction of deformities and relief of pain in the present research could have stemmed from the corrective exercise protocols applied in this work. The first stage involved the release of trigger points through deep muscular massage in water and the myofascial release of stiff muscle via a foam roller [40,41]. These interventions may have improved the participants' flexibility, blood flow, arterial function, vascular endothelial function, and parasympathetic nervous system activity. [41].
Muscle imbalances involve muscular tightness on one side of the body and the crossing of muscular elongation on the opposite side. The resistive forces (bow, drag, and cohesive forces) of water can strengthen muscles and reduce muscle imbalances [38]. In this study, stretching exercises were administered for the pectoralis, superior trapezius, levator scapulae, sternocleidomastoid, and scalene muscles to minimize such imbalances. The static stretching likely induced mechanical and neural adaptations, ultimately increasing the range of motion of the participants and reducing the muscle stiffness that they were experiencing [41].
Static stretching seems to influence the mechanically viscoelastic components of the neuromyofascial tissue. Neurobiologically, the static stretching of neuromyofascial tissue up to the end of range of motion may reduce the excitability of motor neurons through the inhibitory effects of the Golgi tendon organ and the Renshaw recurrent loop [42]. In these abnormalities, long-term poor posture results in some muscles exceeding neutral physiological length. Long-run muscular 13 elongation, in turn, inhibits muscle spindle activity and the creation of additional sarcomeres; this condition is also called "stretch weakness" [3]. With consideration for these issues, this study's participants were instructed to execute chin tuck exercises to strengthen deep neck flexors, rowing to strengthen the rhomboid and inferior trapezius muscles, and combo exercises in the scaption position as well as the T and cobra positions on a gym desk in water [42]. These exercises may facilitate movement in the muscles and strengthen them by stimulating and increasing the response of muscle spindles [3].  [17].
Another source of effectiveness in this work was the proprioception exercises.
Decreased proprioception has been identified as another side effect of postural deformities [3,43]. Thus, the proprioception exercises implemented in this work can give rise to significant improvement in deformity correction as such activities may enhance the response of the central nervous system to afferents for the reorganization and coordination of muscles. After the administration of the sensory motor exercises, integration was performed as the last component of the corrective exercise protocols. Integrated dynamic motions are controlled motions that impose 14 a weak load on individuals as they assume a good postural position. This helps maintain correct joint alignment and enables muscles to function appropriately in activities that involve interaction between length and tension [42]. Integration was implemented by instructing the participants to take part in a purposeful game in water.
The findings likewise pointed to the effectiveness of the protocols in relieving neck and shoulder pain. The significant reduction in pain severity can be attributed to the

Study limitations
Certain limitations remained in the current work, namely, the focus on only male subjects, the small sample size and the small number of groups, the lack of a landbased exercise group, the insufficient time to measure lung volumes for an assessment of how they are affected by deformity correction. 15

Conclusion
The results demonstrated that the implementation of eight-week water-based corrective exercises significantly reduced simultaneously occurring FHP, RSP, and HK. The interventions also significantly minimized the highly prevalent pain accompanying these conditions. The corrective exercise protocols implemented in this work can be adopted by professionals in correcting the aforementioned concurrent malalignments.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Source of Funding
No external funding was received for this study.

Authors' contributions
All authors contributed to the study design. HA collected the data. Data analysis was conducted by FG, the interpretation and discussion of findings were performed by all authors. AY and HA drafted the manuscript and also, all authors reviewed drafts of the paper and approved the final submission.

Acknowledgments
We thank our colleagues from all students who participated in this research and completed the corrective exercises protocol exactly and we would like to express my heartfelt thanks to M.Sc. students who help us in this research.