Kendall Versus Janda's Approach Along With Diaphragmatic Breathing Exercises in Upper Crossed Syndrome

This randomized clinical trial study will be conducted at Central Hospital and Anwer's Polyclinic, Sialkot. We will include 50 patients (25 in each group) of Upper Crossed Syndrome with an age range of 30-50 years, both male and female will be included. Group A will be provided Kendall Exercises with Diaphragmatic breathing exercises, and Group B will receive Janda's with diaphragmatic breathing exercises. Both interventions will be administered for 45 minutes per session, three times per week, for a total duration of six weeks. Outcome measures will include NPRS for pain, Neck Disability Index for disability, Universal goniometer for cranio vertebral angle, and a measuring tape for thoracic expansion will be used. The collected data will be analyzed in the Statistical Package for the Social Sciences (SPSS) 26.0 version. If the data is normally distributed, then a parametric if not normally distributed than a nonparametric test will be applied.

• Kendall exercises (Other): Stretching: Pectoralis, Upper Trapezius, Levator Scapulae (2 sets of 20 sec each) Strengthening: Scapular retractors with Thera band (2 sets of10 reps), Chin tucks (2 sets of 10 reps), Diaphragmatic breathing (4 mins) Strengthening: Add isometric cervical flexors (5 sec hold with 5 reps),, Chin tucks \& scapular retractors (3 sets of 10 reps) Strengthening: Add scapular squeeze (5 sec hold of 5 reps), Emphasize postural control during exercises Strengthening: Functional posture tasks (e.g., seated posture with resistance), Maintain 15 reps of 3 sets Anterior (Wall Slides), Deep Neck Flexors - 2 sets of 10 reps Diaphragmatic breathing (4 mins), Neck Flexor Hold: 30 sec × 3 sets Add Dumbbell Shrugs, Table Pushes - 3 sets of 10 reps Add Serratus Anterior Upper Cuts (3 sets of 10 reps) strengthening increased to 12-15 reps per set (all muscle groups). Functional integration: Posture tasks during daily movement
• Janda's Approach (Other): Stretching: Levator scapulae, Upper Trapezius, Pectoralis (doorway/towel) - 2 sets × 30 sec each, Strengthening: Middle \& Lower Trapezius, Serratus Anterior (Wall Slides), Deep Neck Flexors - 2 sets × 10 reps, Diaphragmatic breathing (4 mins) Neck Flexor Hold: 30 sec × 3 sets Add Dumbbell Shrugs, Table Pushes 3 sets × 10 reps Add Serratus Anterior Upper Cuts (3 sets × 10 reps) strengthening increased to 12-15 reps per set (all muscle groups). Maintain 3 sets of stretching. Functional integration: Posture tasks during daily movement (e.g., reaching, sitting)

Primary outcomes

• NUMERIC PAIN RATE SCALE (NPRS) for pain [upto 6 weeks]: It is a self-reported scale that measures pain intensity on a scale from 0 (no pain) to 10 (worst possible pain). It is widely used in musculoskeletal conditions for monitoring pain levels over time. The NPRS has demonstrated high validity (r = 0.85 with VAS) and excellent test-retest reliability (ICC = 0.92-0.96). The MCID for NPRS is generally considered to be 2 points, indicating a meaningful improvement or worsening in pain perception
• NECK DISABILITY INDEX (NDI) [upto 6 weeks]: It is a validated questionnaire consisting of 10 items that assess the functional impact of neck pain on daily activities such as personal care, work, driving, and recreation. It is specific to cervical conditions. The NDI has strong content validity, with excellent internal consistency (α = 0.87) and test-retest reliability (ICC = 0.89). The MCID for NDI has been reported to range from 5 to 7 points, representing a clinically important change in neck-related disability
• UNIVERSAL GONIOMETER for ROM [Upto 6 weeks]: It is used to measure the craniovertebral angle (CVA), an objective indicator of forward head posture in individuals. A CVA less than 50° typically indicates abnormal posture. This tool shows good validity and excellent intra-rater reliability (ICC = 0.80-0.98) for cervical spine angle measurements. While an exact MCID for CVA is not firmly established, a change of 3-5 degrees is often considered clinically meaningful in postural correction studies
• MEASURING TAPE [Upto 6 weeks]: t is a simple and cost-effective tool used to assess chest expansion, which reflects thoracic mobility and respiratory function. The measurement is taken by placing the tape around the chest at the level of the fourth intercostal space during full inhalation and exhalation. It has acceptable criterion validity and demonstrates high intra-rater reliability (ICC = 0.91-0.94), making it suitable for tracking changes in chest mobility during postural or breathing interventions. The MCID for chest expansion is not universally defined, but an increase of 0.5 to 1.0 cm is generally considered clinically relevant in pulmonary and postural rehabilitation contexts

Sex: All, ages: 30 Years to 50 Years

Inclusion Criteria:

Age between 30 to 50 years old Both male and female are included, Craniovertebral angle less than 50°, Rounded shoulders (on photogrammetry)

Exclusion Criteria:

* Cervical trauma or surgery Congenital scoliosis Spasmodic torticollis Any tumor or trauma History of surgical procedures on neck or lower back Disc issues in neck or lower back

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• Amna Zia, PhD*, Principal investigator, King Edward Medical University
• Kinza Saif, Principal investigator, Riphah International University, Lahore