Comparison of Proprioceptive Neuromuscular Facilitation and Patient Education in Upper Crossed Syndrome

Posture will be assessed using the Posture Screen Mobile (PSM) application (Backbone Software, Inc., USA), a valid and reliable mobile application designed for postural analysis. Participants will be positioned in a static standing posture on a flat surface, with their feet parallel, wearing appropriate clothing that allows visualization of the upper body and lower extremities. Photographs will be taken from the anterior, posterior, and lateral views using a mobile device placed at a standardized distance.

During the assessment, the application will automatically identify anatomical reference points (e.g., ears, shoulders, pelvis). Based on these reference points, postural deviations will be calculated and reported by the software. Anterior and posterior postural deviations in the frontal plane and lateral postural deviations in the sagittal plane will be recorded for each participant.

Muscle strength of the thoracic back extensor muscles and abdominal muscles (upper, lower, and oblique abdominal muscles) will be assessed before and after the intervention using manual muscle testing performed by the same physiotherapist (Scoring 0-5).

Upper abdominal muscle strength will be evaluated in the supine position using graded trunk flexion tasks with varying arm positions as resistance. Lower abdominal muscle strength will be assessed in the supine position by recording the ability to maintain lumbopelvic stability while the lower extremities are slowly lowered from 90° hip flexion. Oblique abdominal muscle strength will be evaluated through trunk flexion combined with rotation, with scoring based on movement quality and scapular clearance criteria.

The level of back pain will be assessed using the Visual Analog Scale (VAS). The VAS consists of a 10-cm horizontal line, with the endpoints labeled "no pain" and "unbearable pain." Participants will be asked to mark the point on the scale that best represents the intensity of their pain. Pain intensity will be determined by measuring the distance in centimeters from the "no pain" anchor to the participant's mark.

Muscle endurance of the thoracic and lumbar back extensor muscles and the abdominal muscles (upper, lower, and oblique abdominal muscles) will be assessed. Endurance of the thoracic and lumbar back extensors will be evaluated using the Biering-Sorensen Test, a valid and reliable method for assessing isometric endurance of spinal extensor muscles. The duration for which the test position can be maintained will be recorded in seconds.

Abdominal muscle endurance will be assessed by recording the holding time (in seconds) at the final position of the highest achievable manual muscle test score. Upper abdominal muscle endurance will be evaluated using the Bench Trunk Curl Test, oblique abdominal muscle endurance will be measured using the Flexion-Rotation Trunk Endurance Test, and lower abdominal muscle endurance will be assessed by recording the duration for which an isometric position requiring lumbopelvic stability can be maintained.

Muscle length tests will be performed for the following muscle groups.

Pectoralis Major (sternal and clavicular portions):

Muscle length will be assessed in the supine position by measuring the distance between the lateral epicondyle of the humerus and the examination table on both sides. The upper limb will be positioned in shoulder external rotation with standardized abduction angles (135° for the sternal portion and 90° for the clavicular portion) and elbow extension. The measured distance will be recorded as an indicator of muscle tightness.

Pectoralis Minor:

Muscle length will be evaluated in the supine position by measuring the distance between the acromion and the examination table bilaterally. Greater distances will indicate increased muscle tightness.

Hamstring Muscles:

Hamstring muscle length will be assessed bilaterally using the straight leg raise test in the supine position. Hip flexion range of motion will be measured with a universal goniometer and recorded in degree

Trunk range of motion, including flexion, extension, lateral flexion, and rotation, will be assessed using a goniometric method. Measurements will be recorded in degrees using Saehan steel goniometers.

Trunk flexion and extension will be measured in the standing position, with the goniometer aligned to anatomical landmarks of the lumbosacral region. Trunk lateral flexion will be assessed in standing, with the goniometer positioned to follow the spinal alignment. Trunk rotation will also be measured in the standing position, and the angle achieved during rotation will be recorded in degrees.

Trunk flexion flexibility will be assessed using the sit-and-reach test. Participants will be seated on a firm surface with the knees extended and instructed to reach forward toward their feet without bending the knees. The distance reached will be measured in centimeters using a measuring tape.

Trunk extension, lateral flexion, and rotation flexibility will be assessed in the standing position. The distances achieved in the respective movement directions will be measured in centimeters using a measuring tape and recorded.