Neck pain and headaches of cervical origin are complaints affecting an increasing number of the general population. It is clear that they are very common and have a considerable impact on the health and quality of life of individuals and on society as a whole [1].

Neck Pain and associated postural disorder mainly affecting the biomechanics of the neck and upper extremities, as well as respiration. It is recommended evaluating respiratory functions in addition to posture examination given the fact that most of the patients with neck pain have a faulty breathing pattern [2].

Neck pain is considered common worldwide with a prevalence ranging from 0.4% to 86.8% [9]. It is considered to be one of the most costly musculoskeletal problems as it is associated with disability and tremendous social, psychological and economical impact on health and quality of life of the individual and on society as a whole [1].

When FHP (Forward head posture) is maintained for prolonged periods the neck flexors and the erector spinae (ES) muscles in the upper thoracic region are weakened due to their lengthening, and the scapula is elevated due to tension in the levator scapula, sternocleidomastoid (SCM), splenius muscles, and the suboccipitalis, which also causes tension in the upper trapezius (UT) [10]. Therefore, because of an imbalance in the muscles, such as the shortening or lengthening, or straining or loosening of the musclesaround the neck, a rounded shoulder posture is exhibited, in which the upper thoracic region is slightly bent while in a sitting posture, and chronic neck pain results due to mechanical stress. These changes in muscle activity result from changes in motor strategies to minimize the activities of muscles that are sensing pain and to compensate for these suppressed muscles [2].

Diaphragmatic Breathing is defined as taking slow, deep breaths through the nose using the diaphragm while lying supine with minimal chest movement, supporting one hand on the chest and the other on the abdomen. During breathing, the doctor should keep the chest as still as possible and concentrate on contracting the diaphragm so that the stomach moves against the hand. Generally, DB practitioners breathe in and out for about 6 seconds [3].

During diaphragmatic breathing exercises, clients are typically instructed to place their hands on their abdomen and upper chest and visually and/or tactilely confirm that their movements are appropriate. During, client position and tactile, auditory, and visual cues are considered key strategies to achieve diaphragmatic breathing. As a general rule, preoperative breathing exercises should be performed as directed by self-training. Proper instruction to ensure the integrity of self-movement is critical to prevent pulmonary complications after abdominal and thoracic surgery [4].

Pursed-lips breathing (PLB) is a maneuver that is frequently taught to patients with chronic obstructive pulmonary disease (COPD) in respiratory physiotherapy programs to improve breathing efficiency and better manage dyspnea during activities of daily living. Researchers first became interested in PLB when emphysema patients were clinically observed to breathe instinctively with the lips semi-closed in an attempt to minimize dyspnea [5].

Peak expiratory flow rate (PEFR) is the volume of air forcefully expelled from the lungs in one quick exhalation, and is a reliable indicator of ventilation adequacy as well as airflow obstruction. PEFR is one of the important parameters in pulmonary function testing that has been evolved as clinical tools for diagnosis, management and follow up of respiratory diseases. For the assessment of ventilatory capacity, Peak Expiratory Flow rate is considered to be the simplest one among the pulmonary function indices which was first introduced by Adorn in 1942 as a measurement of ventilatory function and was accepted in 1949 as an index of spirometry [6].

The maximal expiratory flow rate was measured with the Wright expiratory flow meter. It consists of a cylindrical instrument with a mouthpiece on its circumference. A circular dial is located on one end of the instrument which directly records the flow rate in liters per minute [11]. The patient merely places the mouthpiece in his mouth while holding the instrument in one hand and pinching his nostrils closed with his other hand. After taking a deep breath, he expires maximally into the instrument. It is explained to the patient that he should blow as much air through the instrument as rapidly as he possibly can [12]. Three trials were taken each day and the best of these three used on the graphs [7].

Normal respiration is a very intricate function that comprises mechanical as well as nonmechanical components. It is shown to be affected by various factors including age, lifestyle, disease, and change in posture. With the increased use of hand held devices, everyone is prone to poor sitting postures like forward head posture. The purpose of this study was to evaluate the effect of assumed forward head posture and torticollis on the diaphragm muscle strength. A sample of 15 healthy males, aged 18-35 years, was recruited for this study. All subjects performed spirometry to measure the forced expiratory volume in 1 second (FEV1), the forced vital capacity (FVC), and FEV1/FVC ratio. SNIP was measured during upright sitting, induced forward head posture, and torticollis. Subject’s mean age (SD) was 23(6) years. The SNIP score of the subjects during sitting with FHP was lower as compared to that during upright sitting. It decreased significantly during induced right torticollis position. This is the first study exploring the impact of different head and neck positions on respiratory function. Alteration of head and neck positions had an immediate negative impact on respiratory function. Clinicians should be prompted to assess respiratory function when assessing individuals with mal-posture [7].

Forward neck posture is become increasingly common, as it is becoming leaning forward posture, particularly with popularization of smart phones. Forward head posture is one of the most common deviation from normal cervical posture and may lead to an increase in gravitational load and mechanical stress to cervical facet joints, altered neck extensors muscles activity and length of cervical muscles [8].

In recent years, the number of smart phone users has progressively increased worldwide. Using smart phone for prolonged time will cause faulty posture or poor posture such as forward head posture and rounded shoulders. The structural problems caused by faulty posture can also lead to respiratory dysfunction. The objective of the study was to determine the effect of exercise on posture and respiratory function among smart phone users [8].

Previous research on chronic neck pain syndrome has demonstrated the existence of: (i) decreased strength of deep neck flexors and extensors, (ii) hyperactivity and increased fatigability of superficial neck flexors (especially sternocleidomastoids and anterior scalene), (iii) limitation of range of motion [12-16], (iv) increased forward head position (FHP), (v) decrease in proprioception and neuromuscular disturbances, (vi) existence of pain, and (vii) psychosocial dysfunction.

Patients with chronic neck pain do not have optimal pulmonary function. Cervical spine muscle dysfunction in parallel with pain intensity and kinesiophobia are factors that are associated mainly with this respiratory dysfunction [16].

Aim

To determine the effect of diaphragmatic breathing exercise and pursed lip breathing exercise along with neck isometrics on PEFR among patients in experimental group.

Objective

To study the efficacy of respiratory physiotherapy in preventing neck pain in patients having forward head posture.

Significance of Study

This will help in developing a better treatment protocol for the patients of forward head posture having neck pain, easy to understand the mechanics of neck pain and helping to improve that as faster as possible

Methodology

• Sample 50 subjects of forward head posture with neck pain.
• Study Design Comparative experimental study design.

Method: Subjects meeting the inclusion and exclusion criteria were selected for the study. All the selected subjects were informed in detail about the type and nature of the study. The subjects were requested to sign consent from prior to the study. The protocol was follow:

Instrumentation/Material Required

• Goniometer
• Paper
• Pen
• Sanitizer
• PEFR
• Chair
• Pillow

Significance of Study

This will help in developing a better treatment protocol for the patients of forward head posture having neck pain, easy to understand the mechanics of neck pain and helping to improve that as faster as possible

Inclusion Criteria

• AGE: 30-35 years
• Subjects with forward head posture having neck pain
• Both males and females
• Patient stable and cooperative

Exclusion Criteria

• If they had undergone cervical spine, abdominal or chest surgery
• Hypersensitive patients
• Neck pain of traumatic origin
• If they are having serious comorbidities
• Cervical spondylosis
• Neurological disorders affecting the diaphragm

Outcome Measures

• PEFR
• Neck disability
• Crainocervical angle
• VAS

Data Analysis

In the present study, data analysis was conducted using the PSPP Software and Microsoft excel 2014. The data set consisted of information collected from a total of 50 subjects, With 22 males and 28 females.

To better understand the characteristics of the participants, descriptive statics such as mean and standard deviation (SD) were calculated for 4 variables: 1.PEFR (pre and post) 2.vase (pre and post) 3. Neck disability index (pre) 4.craino cervical angle (pre).

These calculations provided valuable insights into the central tendency and variability of the calculated data, enabling a more comprehensive analysis.

The preceding chapter dealt with methodology, plan and procedure adopted by the researcher to complete the operational part of this research work. The present chapter is concerned with making analysis and interpretation of the data collected during operational stage. In the present study, data was analyzed and interpreted with reference to the objectives of the study. The results arrived after analyses of raw data are presented as follows:

Table 1: Testing Normality of Peak Expiratory Flow Rate for Neck Isometric Exercises with Diaphragmatic Exercise and Pursed Lip Breathing Exercise.

The scores of peak expiratory flow rate for neck isometric exercises with diaphragmatic exercise and pursed lip breathing exercise were noted down and an outline of descriptive statistics namely K-S test were prepared which is shown in Table 1. Table 1 concluded that pre-test peak expiratory flow rate for group I (neck isometric exercises with diaphragmatic exercise) and group II (neck isometric exercises with pursed lip breathing exercise) are normally distributed, as p-values are non-significant. Similarly, post-test peak expiratory flow rate for group I and group II are normally distributed, as p-values are 0.950 and 0.701, respectively.

Table 2: Significance of Mean Differences of the Peak Expiratory Flow Rate in the Neck Isometric Exercises with Diaphragmatic Exercise and Pursed Lip Breathing Exercise.

As shown in table 2, the mean peak expiratory flow rate for neck isometric exercises with diaphragmatic exercise at pre-test phase (267.2) is lesser than post-test phase (281.2) with standard deviation as 52.04 and 53.90, respectively. As t-value for peak expiratory flow rate of neck isometric exercises with diaphragmatic exercise was obtained 9.899, which is significant at 1% level of significance; hence a significant increase in peak expiratory flow rate after neck isometric exercises and diaphragmatic exercise in subjects with forward head posture having neck pain was found. Whereas the mean peak expiratory flow rate for neck isometric exercises with pursed lip breathing exercise at pre-test and post- test phase were 269.20 and 312.40 with standard deviation as 56.43 and 52.54, respectively. On the other hand, the obtained „t-value? of neck isometric exercises with pursed lip breathing exercise was found to be 7.718, which is significant at 0.01 level. It means a significant increase in peak expiratory flow rate after neck isometric exercises with pursed lip breathing exercise in subjects with forward head posture having neck pain was observed.

Table 3: Significance of Mean Differences of the Peak Expiratory Flow Rate in the Neck Isometric Exercises with Diaphragmatic Exercise and Pursed Lip Breathing Exercise for Pre-test Stage.

Perusals of Table 3 indicate that the average peak expiratory flow rate for neck isometric exercises with diaphragmatic exercise at pre-test phase was obtained 267.2 with standard deviation as 52.04 whereas the mean pre-test peak expiratory flow rate for neck isometric exercises with pursed lip breathing exercise was 269.20 with standard deviation as 56.43. On the other hand, the obtained „t-value? of both groups were found to be 0.130, which is not significant at 0.05 level. It means the there is no significant difference of peak expiratory flow rate among neck isometric exercises with diaphragmatic exercise and neck isometric exercises with pursed lip breathing exercise at pre-test phase. Thus Hypothesis H03 i.e. “There is a significant effect of neck isometric exercises with diaphragmatic exercise and pursed lip breathing exercise on pre-test PERF on the subjects with forward head posture having neck pain” is rejected at 5% level of significance.

Figure 1: Pre Test PEFR.

Table 4: Significance of Mean Differences of the Peak Expiratory Flow Rate in the Neck Isometric Exercises with Diaphragmatic Exercise and PursedLip Breathing Exercise for Post-test Stage.

Table 4 revealed that average peak expiratory flow rate for neck isometric exercises with diaphragmatic exercise at post-test phase was obtained 281.2 with standard deviation as 53.9 whereas the mean post- test peak expiratory flow rate for neck isometric exercises with pursedlip breathing exercise was 312.4 with standard deviation as 52.54. On the other hand, the obtained „t-value? of both groups were found to be 2.073, which is significant at 0.05 level. It means the peak expiratory flow rate after neck isometric exercises with pursed lip breathing exercise is better than neck isometric exercises with diaphragmatic exercise at post-test phase. Thus, Hypothesis H04 i.e. “There is a significant effect of neck isometric exercises with diaphragmatic exercise and pursed lip breathing exercise on post-test PERF on the subjects with forward head posture having neck pain” is accepted at 5% level of significance.

Figure 2: Post Test PEFR.

The present study was conducted to find out the Therapeutic Effects of Isometric Neck Exercise with Diaphragmatic Breathing Versus Pursed Lip Breathing on Subject with Forward Head Posture having Neck Pain [14]. The study measured CVA, vase, neck disability index and PEFR as parameters to demonstrate the effect of change in cranio cervical angle on change in respiratory function [15-17].

Previous study performed in other context and population, support our results of PEFR after a giving the subjects two different types of breathing exercise and neck isometrics along with them. Studies have reported decrease in neck pain after a protocol of breathing exercise for a certain period of time [13].

This study indicates that a targeted exercises program, can result in the improvement of values of PEFR [16]. The mean values of pefr pre-test for group 1 is 267.20 and group b 2 is 269.20 and post-test group 1 is 281.20 and group 2 is 312.40 [14].

The result showed that statistically highly significant difference in the values of PEFR.

The present study concluded that peak expiratory flow rate after neck isometric exercises and diaphragmatic exercises significantly increased among subjects with forward head posture having neck pain.

Similarly, peak expiratory flow rate after neck isometric exercises with pursed lip breathing exercises significantly increased among subjects with forward head posture having neck pain.

The present study also conveys that peak expiratory flow rate after neck isometric exercises with pursed lip breathing exercises (312.4) was significantly better than neck isometric exercises with diaphragmatic exercises (281.2) among subjects with forward head posture having neck pain.

Small sample size was analysed in this study. The duration of the study was short. Long term follow up of the subject was not possible.

1. Nair SP, Panchabhai CS, Panhale V. Chronic neck pain and respiratory dysfunction: a review paper. Bull Fac Phys Ther. 2022; 27: 21.
2. Shah M, Shah S, Ved V. A Study to Evaluate Correlation between Respiratory Function Measures – MVV, FEV1, FVC and FEV1/FVC Ratio to Pain, Disability Index and Craniocervical Angle in Persons with and without Chronic Neck Pain. Indian J Physiotherapy and Occupational Therapy - An Int J. 2023; 17.
3. Hamasaki H. Effects of Diaphragmatic Breathing on Health: A Narrative Review. Medicines (Basel, Switzerland). 2020; 7: 65.
4. Yokogawa M, Kurebayashi T, Ichimura T, Nishino M, Miaki H, Nakagawa T. Comparison of two instructions for deep breathing exercise: non-specific and diaphragmatic breathing. J Phys Ther Sci. 2018; 30: 614-618.
5. Granda Orive JID, Garcia Rio F, Vazquez FR, Sacristan JE, Jimenez TG, Sanchez LC. Archivos de bronconeumologia. 2004; 40: 279-282.
6. Jason Long, Peak expiratory flowrate, University of Glasgowe Wadhwa D, Chhajed B, Hande D. Is there any effect of abdominal muscle exercises on peak expiratory flow in normal individuals? Int J Health Sci Res. 2016; 6: 192-198.
7. Lee NK, Jung SI, Lee DY, Kang KW. Effects of Exercise on Cervical Angle and Respiratory Function in Smartphone Users. Osong Public Health Res Perspect. 2017; 8: 271-274.
8. Anwar S, Arsalan SA, Zafar H, Ahmad A, Gillani SA, Hanif A. Intrarater reliability of cervical range of motion device in measuring cervical active range of motion in patients with chronic neck pain and respiratory dysfunction. Anaesthesia, Pain and Intensive Care. 2022; 26.
9. Ahmad A, Kamel K, Mohammed R. Effect of forward head posture on diaphragmatic excursion in subjects with chronic neck pain. A case-control study. Physiotherapy Quarterly. 2020; 28: 9-13.
10. Koseki T, Kakizaki F, Hayashi S, Nishida N, Itoh M. Effect of forward head posture on thoracic shape and respiratory function. J Phys Ther Sci. 2019; 31: 63-68.
11. Han J, Park S, Kim Y, Choi Y, Lyu H. Effects of forward head posture on forced vital capacity and respiratory muscles activity. J Phys Ther Sci. 2016; 28: 128-131.
12. Hristara-Papadopoulou A, Tsanakas J, Diomou G, Papadopoulou O. Current devices of respiratory physiotherapy. Hippokratia. 2008; 12: 211-220.
13. Jahan S, Kumar L, Ahmed F. Comparison of Effects of Flutter Device versus Autogenic Drainage on Peak Expiratory Flow Rate, Oxygen Saturation, Respiratory Rate and Pulse Rate in COPD Patients. J Novel Physiotherapy and Physical Rehabilitation. 2015; 10.
14. Allam N. Effect of Combination of Acapella Device and Breathing Exercises on Treatment of Pulmonary Complications after Upper Abdominal Surgeries. J Surgery. 2016; 4; 10.
15. Dimitriadis Z, Kapreli E, Strimpakos N, Oldham J. Pulmonary function of patients with chronic neck pain: a spirometry study. Respiratory care. 2014; 59: 543-549.
16. Kapreli E, Vourazanis E, Billis E, Oldham JA, Strimpakos N. Respiratory dysfunction in chronic neck pain patients. A pilot study. Cephalalgia: An International J headache. 2009; 29: 701-710.
17. Kapreli E, Vourazanis E, Strimpakos N. Neck pain causes respiratory dysfunction. Medical hypotheses. 2008; 70: 1009-1013.