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Abstract

[Purpose] This study performed to investigate the effect of elastic band exercise programon the posture of subjects with rounded shoulder and forward head posture. [Subjects andMethods] The body length, forward shoulder angle, craniovertebral angle, and cranialrotation angle of participants (n=12) were measured before and after the exercise program.Furthermore, the thicknesses of the pectoralis major, rhomboid major, and upper trapeziuswere measured using an ultrasonographic imaging device. The exercises program wasconducted with elastic bands, with 15 repetitions per set and 3 sets in total. [Results]The length of the pectoralis major, forward shoulder angle, and craniovertebral angleshowed significant changes between before and after the exercise program, whereas thechanges in the other measurements were not significant. The thickness of the uppertrapezius showed a significant increase between before and after the elastic bandexercise. [Conclusion] These findings suggest that the elastic band exercise program usedin the study is effective for lengthening the pectoralis major and correcting roundedshoulder and forward head posture.

INTRODUCTION

Most people employed in economic activities complain neck, shoulders, and lower backdisease. In particular, when one uses a computer in an inappropriate posture for a longtime, the centerline of the head moves forward and upward, which causes an increase in theweight of the head supported by the neck, ultimately resulting in changes in the head, neck,and areas connecting the shoulders^{, )}. If the head is located anteriorly for longperiods, the bending moment of the head increases, and compensatory excessive straighteningof the upper neck joints and atlanto-occipital joints is required to fix the gaze to thefront. This can cause shortening of the posterior head and neck muscles, and the upper neckbones can protrude relatively forward when the face is oriented upward^{3, 4)}. Moreover, due tostructural characteristics, this can cause rounded shoulder with rounding of the back⁾. Rounded shoulder is a typical bent posturein which the scapulae are elevated and the acromion is protruded forward in comparison withthe center of gravity of the body. The angle between the lower neck bone and upper back bonewas increased, and the protraction, upward rotation, and anterior tilt of the scapulae wereincreased^{, 7)}. Such changes cause imbalance in the surrounding muscles andeventually cause pain in the head, temporomandibular joints, neck, back, shoulders, andarms^8,9,,).

Changes in the skeletal alignment can indicate imbalance in stretching and shortening ofmuscles, imbalance in use of antagonist and agonist muscles, or skeletal defects thatpromote such muscular changes, and inappropriate postures aggravate pain and damage.Therefore, various posture correction programs that can correct skeletal alignment, decreasepain, and facilitate recovery of tissue and changes in the body have been suggested¹²⁾. Although surgeries that can result infast improvements within a short period are drawing attention, surgery alone cannot be usedas the optimal treatment because symptoms can recur even after treatment of malpositionedvertebrae due to imbalance in peripheral soft tissues.

An elastic band is a rubber band with elasticity and resistance, and the velocity andintensity of the resistance of an elastic band can be controlled. Elastic bands can be usedto apply resistance in a way that is different from that of exercise equipment with weightssuch as dumbbells. Moreover, they can be used in various ways just as exercise can beperformed in all directions. Considering that exercise using elastic bands, which are easyto carry, is economical and safe, elastic bands can be used to improve muscular strength,flexibility, and balance control in the elderly and young, regardless of gender^,,). Exercise using elastic bands can beapplied not only to ordinary people but also to patients with diseases. The application ofelastic resistance band exercise programs to orthostatic hypotensive elderly was reported tobe a safe method of improving strength, functional ability, and physical activity⁾. The application of elastic band exerciseprograms in patients with chronic obstructive pulmonary disease was found to increase thepatients’ functional capacity and muscular function⁾. The effects of elastic band exercise programs have been reportedto improve physical and postural control. However, programs for people with forward headposture and rounded shoulder are lacking. In the present study, we investigated the effectof an elastic band exercise programs on physical alignment and changes in related muscles insubjects with rounded shoulder and forward head posture.

SUBJECTS AND METHODS

Subjects (n=12; the distance between on the table and the acromion>2.5 cm) with roundedshoulder and forward head posture were included in the study⁷⁾. Subjects who had scapula damage, had previously received surgery onthe neck bone or upper limbs, or had other diseases were excluded. The study subjectsperformed 3 sets of the exercise program with 15 repetitions per set. Measurements were madebefore and after the exercise. Before the program, the purpose of the study was explained tothe subjects, and only the subjects who agreed to participate in the study were included.Kyungnam University approved this study, which complies with the ethical standards of theDeclaration of Helsinki. Table 1 presents the general characteristics of the subjects.

Table 1.

The exercise program included the following exercises: 1) a lat pull down, 2) a shoulderexternal rotation exercise, 3) shoulder horizontal abduction exercise, 4) a seated bend row,5) a shoulder abduction exercise, 6) a shoulder flexion exercise, and 7) a shoulderextension exercise. For the lat pull down, the subjects held both ends of the elastic bandwhile lifting the arms to shoulder width. They stretched the band slowly in both directionsand pulled it down to their chest. The abdomen remained contracted while performing theexercise. 2) For the shoulder external rotation exercise, the subjects bent their arms to90°and oriented their palms toward the ceiling, while their elbows at the height of theflank. They held the elastic band and slowly stretched it while rotating their shouldersexternally. They were instructed to not move the elbows forward. 3) For the shoulderhorizontal abduction exercise, the subjects extended their arms in front of their body at90°and placed them shoulder-width apart. Their palms were oriented to face the ground, andthey held the elastic band. They then stretched the elastic band horizontally while payingattention to keep their elbows straight. 4) For the seated bend row, the subjects placed theelastic band such that their feet were located at the middle of the band. They then sat on achair and held the ends of the elastic band. The subjects stretched the elastic band as iftheir elbows were being put together and drew their shoulders together. 5) For the shoulderabduction exercise, the subjects stepped on the elastic band with the foot on the side beingexercised, held the elastic band with on hand, and kept the hand low in its neutralposition. They then opened the shoulders with the elbows slightly bent. 6) For the shoulderflexion exercise, the subjects stepped on the elastic band with the foot on the side beingexercised, held the elastic band with one hand, and kept the hand low in its neutralposition. They then bent the arm forward with the elbow straightened. 7) For the shoulderextension exercise, the examiner held one end of the elastic band, and the subject held theother. The subject started by holding the elastic band low in its neutral position, and thenthey extended the arm backward with the elbow straightened as much as possible. Thefollowing body measurements were ascertained: 1) height of the acromion, 2) distance betweenthe third vertebra and the acromion, 3) distance between the third thoracic vertebra and theinferior angle of scapula, 4) distance between the inner surface of the scapula and thevertebrae, and 5) length of the pectoralis major. For the height of the acromion, theexaminer measured the distance between the table and the acromion⁷⁾ while the subject was in the supine position. For thedistance between the third vertebra and the acromion, the distance between the acromion andthe middle of the spinous process of the third thoracic vertebra was measured^{, )}. For the distance between the third thoracic vertebrae and theinferior angle of the scapula, the inferior angle of the scapula and the spinous process ofthe third thoracic vertebra were marked, and then the distance between the two points wasmeasured with a tape ruler. For the distance between the inner surface of the scapula andthe vertebrae, the horizontal distance from the scapula to the vertebrae was measured with atape ruler. For the length of the pectoralis major, the subject sat in a comfortable sittingposition in a chair, and the examiner marked the middle of the sternal notch and the innerside of the coracoid process by using a marking tape and measured the distance between thetwo points with a tape ruler^{, )}. All measurements were performed on the dominant side. Inorder to measure the thicknesses of the pectoralis major, rhomboid major muscle, and uppertrapezius muscle, a diagnostic ultrasonographic imaging device (SonoAce X8, Samsung,Medison, Republic of Korea) was used in the B-mode setting. The thickness of the pectoralismajor was measured by first drawing a line between the halfway point of the sternum and thelateral lip edge of the bicipital groove. A 7.5-MHz linear probe was used as the axis tomeasure the thickness at the halfway point of the line. The thickness of the rhomboid majormuscle was measured by first drawing a line between the inner surface of the scapula and themidpoint between the spinous processes of the third (T3) and fourth (T4) thoracic vertebrae,and a 7.5-MHz linear probe was used as the axis to measure the thickness at the halfwaypoint of the line. The thickness of the upper trapezius muscle was measured by first drawinga line between the acromion process and the spinous process of the second thoracic vertebra(T2). A 7.5-MHz linear probe was used as the axis to measure the thickness at the halfwaypoint of the line.

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Forward shoulder angle was measured by attaching markers to the tragus, seventh cervicalvertebra (C7), and acromion of the subjects and based on sagittal images. ImageJ (version1.48) was used to measure the angle. For the craniovertebral angle (CVA), the angle betweenthe vertical line and the line connecting C7 and the tragus was measured. For the cranialrotation angle (CRA), the angle between the line connecting C7 and the tragus and the lineconnecting the external canthal angles of the eyes was measured.

SPSS version 14.0 for Windows was used for the statistical analyses. In order to verify theeffects observed in the subjects before and after the exercise program, paired t-tests wereconducted. The level of significance was set at p<0.05.

RESULTS

When the distance from the bed and the acromion of the subjects was measured in the supineposition, the mean pre- and post-exercise distances were 6.1 ± 2.6 cm and 6.2 ± 1.6 cm,respectively. The mean pre- and post-exercise distances between T3 and the acromion were21.5 ± 2.1 cm and 21.9 ± 1.2 cm, respectively. The mean distances between T7 and theinferior angle of the scapula were 16.5 ± 1.8 cm and 16.4 ± 1.5 cm before and after theexercise, respectively. The distance from the thoracic vertebrae to the inner surface of thescapula was 8.7 ± 1.3 cm before the exercise program and 8.6 ± 1.2 cm after the program. Thelengths of the pectoralis major before and after the exercise program were 12.9 ± 1.9 cm and17.6 ± 1.4 cm, respectively. The pre- and post-exercise measurements indicate that thelength of the pectoralis major showed a statistically significant change (p<0.05),whereas the other measurements did not (p>0.05; Table 2).

Table 2.

Ex: exercise; *p<0.05 compared to pre-ex group

The pre- and post-exercise forward shoulder angles were 32.2 ± 6.2° and 29.5 ± 5.7°,respectively. CVA was 46.5 ± 3.7° before the exercise program and 50.0 ± 4.9° after theexercise program. The pre- and post-exercise CRAs were 164.0 ± 7.0° and 162.1 ± 6.8°,respectively. Although statistically significant differences were observed in the pre- andpost-exercise measurements of forward shoulder angle and CVA (p<0.05), no significantdifference was observed in CRA (p>0.05; Table3).

Table 3.

Ex: exercise; CVA: craniovertebral angle; CRA: cranial rotation angle; *p<0.05compared to pre-ex group

The thickness of the pectoralis major before and after exercise was 1.2 ± 0.5 cm and 1.2 ±0.4 cm, respectively. The thickness of rhomboid major before and after exercise was 1.1 ±0.3 cm and 1.1 ± 0.3 cm, respectively. Thickness of upper trapezius before and afterexercise was 0.8 ± 0.2 cm and 1.0 ± 0.2 cm, respectively (Fig. 1). Although statically significant differences were observed in thickness of the uppertrapezius (p<0.05), no significant difference was observed in thickness of the pectoralismajor and rhomboid major (p>0.05; Table4)

Thickness of upper trapezius using ultrasonography

Table 4.

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*p<0.05 compared to pre-ex group

DISCUSSION

Ideal posture refers to a state in which body parts receive the minimum amount of stressagainst gravity and the position of the body is appropriately aligned in space.Inappropriate posture can cause inappropriate movements of the joints by affecting the levelof tension and contraction of muscles, which can cause pain. Therefore, good posture is ameasure of health⁾. Typical posturalchanges were caused by inappropriate posture include forward head posture and roundedshoulder.

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In forward head posture, the pectoralis major and pectoralis minor contract, and therhomboid muscles weaken⁸⁾. If subscapularmuscles cannot create an appropriate muscular counterbalance, the head of the humerus canglide anteriorly, the shoulder girdle can descend, or lifting of the scapula can becomedifficult, leading to functional problems in the pectoralis major⁷⁾. In comparison between the pre- and post-elastic bandexercise measurements of the subjects with rounded shoulder, we found that the length of thepectoralis major increased by 5 cm. This means that the distance between the sternum and thelateral lip of the bicipital groove increased, and consequently, the pectoralis major, whichwas shortened previously, was thought to be stretched. Moreover, shortening of thepectoralis major, which contributes to rounded shoulder, seems to be relieved. However, nostatistically significant difference was observed in the distance between the bed and theacromion, the distance between the acromion and the third vertebra, the distance between thethird vertebra and the inferior angle of scapula, and the distance between the vertebrae andthe inner surface of the scapula. This is believed to be due to the exercise program beingapplied only for 40 minutes per session and being unable to produce greater effects.

In forward head posture and forward shoulder angle, the head is located anteriorly from thecenterline and seems rotated. This is because the upper cervical vertebra is straightened asthe chin is held upward for correction of gaze. Moreover, this causes structural stressaround the neck, which in turn causes shortening or excessive tension of the surroundingmuscles⁾. Forward head posture can beevaluated by measuring the CVA and CRA. Forward head posture is diagnosed when the CVA isless than 50° and the CRA is greater than 145°⁾. When comparing the forward shoulder angles measured before andafter the elastic band exercise program, we found that the forward shoulder angle decreasedby 8.41% and that the CVA increased by 7.48%, showing a significant difference. However, nosignificant difference was observed in CRA. Decreased forward shoulder angle and increasedCVA mean that the head has moved closer to the gravity line connecting the auricle and theacromion process. In other words, rounded shoulder and forward head posture are changinginto good posture. Although the elastic band exercise program was conducted only once in thestudy, we could confirm changes in the length of the pectoralis major and observe movementof the head and neck bone alignment to close to the gravity line. Exercise programs withelastic bands, which are easily accessible, can be used effectively in the correction ofposture, without temporal and spatial limitations.

The limitations of this study include the following: As the number of subjects in thisstudy is small, generalization of the results is difficult. Moreover, the exercise programwas conducted only once, and the same type of elastic band with the same strength was usedfor all the subjects, without consideration of their muscle strength. In future studies,exercise programs need to be applied for longer periods. In particular, studies on exerciseprograms that use elastic bands with strengths appropriate for individual subjects aredeemed necessary.

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