The present quasi-experimental study investigated the effect of multi-modal spinal strength exercise protocols on hyper kyphosis abnormalities in two groups, control and experimental. The ethics code of this study is IR.UT.REC.1395018.  The statistical population of the study included non-athlete students aged 18 to 28 years of age at Zanjan universities. The students who had postural kyphosis abnormalities (≥ 42 degrees) were identified from general physical education classes by research colleagues and introduced to the examiner. After an evaluation of the kyphosis angle, the researcher divided the number of eligible individuals (97 individuals) into two experimental and control groups randomly based on the criteria for entering and leaving the study. The following reasons resulted in the dismissal of individuals from the research sample: pathological symptoms, history of fractures, surgery or joint diseases (especially in the spine), hip or shoulder belt, lower cross syndrome, regular physical activity, championship or membership in sports teams, certain occupational conditions (which exacerbate kyphosis abnormalities and not be able to modify the physical condition in the workplace), reluctance in the participation or continual of the exercises, absence in 2 consecutive exercises sessions and 3 alternate sessions of the 12-week training program and absence at measurement sessions of dependent variables in pre-test or post-test research. After completing the informed consent, the subjects were randomly assigned to one intervention group (selected exercises program) and one control group and then, all of them participated in a pre-test.
A flexible ruler was used to measure the kyphosis angle so that the spinous process of T2 and T12 vertebrae were used as the primary and final points of the kyphosis arcuate arch (31-34). In order to determine the spinous process of T2 vertebrae, the examiner stood behind the subject and asked him to bend his head. In this situation, two prominences are seen at the end of the cervical region, which is the spinous process of the C6 and C7 vertebrae. Then, at the touch of the two prominences, the examiner asks the subject to slowly turn his bent head posteriorly. In such a situation, one of the prominences of the C6 disappears under the hands of the examiner, and only one prominence is touched, which is the spinous process of the C7 vertebrae. Now, with the identification of the spinous process of the C7 vertebrae, it is easy to determine the tufts of the T1 and T2 vertebrae by pinching down and along the spine, respectively. In the present study, after identifying the T2 vertebrae, the initial point of the kyphosis arch was marked with Landmark. The Hoppenfeld method was also used to find the T12 vertebrae, which has been used in many other studies (35).
In this method, the examiner stood behind the subject and asked him to slightly bend his body forward from the waist and reach his hands towards the bed in front of him, while transferring his weight onto his hands. This is done to reduce the activity of the extensor muscles and subsequently allow for an easy evaluation of the spinous process of the spine. In such condition, to reach the spinous process of the T12 vertebrae, the lower edge of the twelfth rib was touched on both sides by the thumb, with both thumbs simultaneously moved upwards and inwards on both sides of the body, until the rib was disappeared underneath the soft tissue. At that time, the midpoint of the line between both thumbs was marked as the spinous process of the T12 vertebrae (the end point of the kyphosis arch) with a Landmark.  Finally, after identifying the bone markers required for the measurement of kyphosis in the breast, the subject was asked to stand naturally and comfortably, look forward and place his weight on the same foot (legs to be apart as 10-15 cm and completely naked). 30 seconds was provide to allow the body to reach its natural and comfort state. A flexible ruler was then used on the thoracic kyphosis of the individual to take the shape of the arc. After fixing the flexible ruler on the kyphosis area, the points were marked with a marker in contact with the middle part of the landscapes, and were removed without any change in the form of a flexible ruler and they were removed slowly and carefully from the spine and were placed on a graduated paper. Then, the curvature of the ruler was drawn on paper and the T2 and T12 points were determined. To calculate the kyphosis angle on the obtained shape from the flexible ruler, first, the T2 and T12 points were connected with a straight line and drawn from the deepest linear curvature point to the T2 and T12 lines. These two lines were called L and H, respectively. Their values were calculated with the formula (θ = 4 Arc tang (2h/l) and the kyphosis angle was calculated accordingly (31-34).
At the next step, standard anthropometric and demographic data related to height, weight, and age were collected using stroke and digital scales from all subjects and were recorded on special sheets. Subjects in the control group continued their daily routine without any specific exercises, while the intervention group controlled the selected exercises for 12 weeks (three sessions per week and 60 minutes each session) under the direct supervision of the examiner. At the end of this period, all subjects in the experimental and control group were once again evaluated and the variables were measured at post-test with the same trend at pre-test. The subjects of the participating group were divided into 4 groups of 10 and a group of 7 individuals. During the exercise period, the researcher assured that there was a trainer for each 5 individuals, so that in each of the 5 training groups, one collaborator helped the research in addition to the researcher implementing the exercise protocols. The exercise program consisted of three main sections that included spinal strengthening, spinal alignment and exercises for increased spinal mobility. The program of training designed with more fold musculoskeletal injuries are related to hyper kyphosis, consisting weakness of spinal extensor muscle, reduced spinal mobility and inferior postural alignment. The intensifying component of spine adapted the strengthening exercise with high intensity designed to strengthen spinal extensors and make stable the trunk in neutral alignment.
Exercises gradually progressed in intensity using Thera-Band or weight resistance with low (30%–40%), moderate (50%–60%), and high-intensity (70%–80%) resistance according to perceived exertion until a Borg scale intensity of 4 to 5 was reached.
The movements of this part included: supine transverse abdominal on a roller (10^R×1^Set) quadruped arm and leg lift (8^R×2^Set); spine extension in prone trunk lift to neutral (8^R×2^Set); side-lying thoracic rotation/extension (8 ^R× 1 ^Set) and side-lying hip abduction/external rotation (8^R×2^Set) (Figure 1-1-1-5). The spinal alignment component integrates spinal extensor strength and mobility into practice. The movements of this part include: Marching on roller (10^R×1^Set), unilateral overhead reaching on roller (10^R×1^Set), bilateral pull-down supine on roller (10^R×1^Set), Shoulder flexion/thoracic extension at wall (10^R×1^Set), wall push-ups  (10^R×1^Set) and single-leg stance (10^R×1^Set) (Figure 2) (6-11). The spinal mobility component is performed with foam rollers and end-range exercises to enhance spinal rotation and extension and decrease the mobility limitations around the anterior shoulders, chest, and spine. Participants lie supine on foam rollers and fulfill side lying and standing end-range thoracic extension and rotation to mobilize the spine during exercise.
The movements included chest and spine stretching supine/roller (1^set×30 sec. passive stretching), gluteal stretching (1^set×30 sec. passive stretching), supine straight-leg raise (1^set×30 sec. passive stretching), prone hip/quadriceps stretch (1^set×30 sec. passive stretching), quadruped thoracic extension stretch (1^set×30 sec. passive stretching), and Neck/chest stretch standing (1^set×30 sec. passive stretching) (Figure 3) (12-17). The intensity of the exercises was increased during the study, with an emphasis on the quality of the movement. The participants maintained the training intensity on the basis of the Borg scale on 4 to 5 (70-80%) perceived pressure. Subjects also received tutorials on postural exercises through audiovisual and feedback that taught them to maintain and improve spinal cord neutralization during training sessions. The subjects were trained to make the length of the exercise program and the daily activities of the head keep the head along the pelvis, and while bending the knee or pelvis, during the activities, the head is aligned with the backbone in a neutral and stable position. In this study, the images were prepared from an ideal spine alignment in neutral position during functional activities such as sitting, standing, and sitting to standing and sleeping. Statistical analysis was performed using SPSS 23 (SPSS Inc., Chicago, Illinois, USA). According to the result of the one sample Kolmogorov-Smirnov test (P>0.05). Based on the above conditions, a covariance analysis was used to examine the difference between the experimental and control groups.

Table 1. Spinal strengthening exercise



Table 2. Spinal alignment exercise


Table 3. Spinal mobility exercise

 

For intragroup changes, T-test was used, and one-way variance analysis and Bonferroni post hoc test were used to compare the groups. Data analysis was performed using SPSS software (SPSS Inc., Chicago, Ill., USA).

 

Table 1 provides the baseline demographic data of all participants. The independent t-test showed no significant difference between the experimental t and control groups in all baseline variables.
The results of a paired-samples t-test demonstrate that the experimental group showed a significant reduction in kyphosis angle 48.00 (3.01) to 40.76 (2.30) (P>0.05). There weren’t any significant changes between pretest and posttest kyphosis angle (P>0.05) (Table 2).
Posttest kyphosis angle between treatment and control groups was compared using ANCOVA after for pretest adjustments (Table 2). Results showed that kyphosis angle was significantly lower in the experimental than in the control group in measuring with flexible ruler (F=535.61 P>0.05) with strong effect sizes (partial eta-square>0.14) (Table 2).
 

Table 3. Physical and anthropometric characteristics of subjects


Table 4. The changes of ALT, ALP, AST and LDH enzymes in each group due to aerobic and anaerobic activity


Table 5. Bonferroni post hoc test results between aerobic-anaerobic groups

Discussion

In a randomized controlled study, out of 97 young male participants, that 47 participants participated in the selected exercise program (spinal strengthening, spinal alignment, spinal mobility) with posture training in the active group an hour for thrice a week for the duration of 12 consecutive weeks. A decrease of 7.24 degrees was observed in the kyphosis angle of the thoracic compared to the control group, and the mean score was 48±3.01 in the pre-test which reached to 40.76±2.30 degree in the post-test. The results of the covariance analysis indicated that the corrective program had a significant effect on the reduction of kyphosis angle. The results of this study were in accordance with the findings of Katzman (2017), Jang (2015), Bansal (2014), Feng (2018), Yoo (2013) and Yelfani (2015) who reported a significant decrease in the kyphosis angle after the implementation of the exercise program (22, 29, 30, 36, 37, 38).
In hyper kyphosis, the implementation of a spinal strength training protocol along with spinal alignment and spinal mobility can simultaneously reduce the kyphosis angle of affected individuals (29). Trunk muscles contribute to the control of movement and stability of the spine, yet the body’s deep muscles and central parts play a vital role in controlling intervertebral movements, which also brings stability to the spine in dynamic situations (39). In the training program, this study attempted to strengthen the muscles of the extensor, the core muscles the central area body, and provide strengthening. In exercises, we also investigated chest muscles stretches and increasing the chest and anterior chest expansion and spinal movement. In this exercise program, we tried to perform more exercises in the close chain and in the case of weight bearing on the roller foam (40). These corrective programs maintain the spine and movement and permit the body to keep the orientation of the spine automatically during static and dynamic loads (36). Researchers have indicated that the following changes are created in skeletal muscle resistance training, including the increase of the total contractile protein, especially in myosin fibers, the increase of the amount and strength of tissue, the increase of the capillary density, the increase of the number of myofibril. Consequently, the longitudinal division of the blade muscle increases muscle strength and endurance. It has also been argued that flexibility exercises act as a coordinator of the agonist and antagonist muscle (41). Therefore, the performed exercises in this study are likely to increase the length of the anterior chest muscles and increase the strength of the back extensor muscles and central area of the body, thereby, leading to a reduced amount of abnormality.
In the present study, the consequence efficacy of corrective exercises was observed in the decrease of the kyphosis angle (7.24 degrees). One of the most important causes of the effectiveness of this study is the use of selected strength and stretching exercises simultaneously with postural training, which led to the decrease of the kyphosis angle by coordinating agonist and antagonist muscles (29). In this study, the training of postural exercises were used through audiovisual and feedback for active members of the group, so that they could use these strategies during the training period and daily activities, as they were taught to maintain a neutral spine status and alignment at all time and improve this situation during exercise. The subjects were trained to keep their head along the pelvis during their daily routine and exercise, while bending the knee or pelvis during the activities in a neutral and stable position along the spine. Katzman et al. (29) examined the efficacy of a strength exercise program for the spine with postural exercises among men and women aged 60 and older with thoracic kyphosis over 40 degrees. After 6 months of exercise and measurement with a kyphometer, results showed that kyphosis had significantly decreased (3.8 degrees). This data was consistent with the results of this research. The main reason for the slow decrease in the kyphosis angle of Katzman's research may be due to the effect of age on the rate of kyphosis. It has also been noted that some subjects had idiopathic kyphosis which affected their final results.
In a study by Feng et al. (2018) entitled, “The effect of a corrective functional exercise program on postural thoracic kyphosis in teenagers: a randomized controlled”. The corrective functional exercise program of the mentioned study above achieved a clinically significant decrease in TKA (approximately 9 degrees), as well as changes in the sacral angle and thoracic ROM (30), which is consistent with the results of this study. In the study of Seiedi et al. (2014), the effect of local and comprehensive correction exercises on the kyphosis angle of young individuals were studied. The researchers concluded that comprehensive exercises had a greater effect on the reduction of kyphosis curvature rate versus local exercises (28). In full grown males, a program with involvement of stretching and flexion of the thoracic vertebrae and training of muscle strength released pain and reduced thoracic kyphosis by 7 degrees (30). Bansal et al. (2014) reported in a review that studies on the effect of training intervention on kyphosis are not only of low quality but have small samples sizes and mainly produce research of moderate efficacy in improving an individual’s kyphosis angle. Similarly, studies that had a randomized controlled trial, this effect was more favorable and ultimately suggested that randomized controlled studies were carried out with a high sample size (22). The researchers of this study, by considering the results of domestic and international performed researches and review studies on the effect of intervention on hyper kyphosis, which mainly recommended the implementation of simultaneous strength and stretching exercises along with postural exercises with a randomized controlled trials with a high sample size, attempted to correct functional kyphosis in young people, as the performed exercises in this study were similar to Katzman's exercises, derived from a corrective exercises series to correct hyper kyphosis abnormalities, which its favorable results has been published on reducing the angle of hyper kyphosis on the elderly (29).
Hence, the investigator, while implementing the exercise program (spinal strengthening, spinal alignment and exercises for increased spinal mobility), simultaneously, also used postural exercises to increase the exercise's usefulness for the participating group in order to control the effective reduction and long-term effects of exercises on hyper kyphosis anomalies.
In this study, 97 subjects with hyper-kyphosis abnormalities were selected in relation to a randomized controlled trial. According to the findings of this study regard the optimal effect of corrective exercises in this study, along with postural exercises in improving hyper-kyphosis in young people, it is suggested to researchers and professionals to use these exercises in combination with posture correction exercises.

 

Conclusion

The results of this study revealed that one session of exhaustive aerobic and anaerobic exercise increases the levels of liver enzymes ALT, AST, ALP and LDH. Overweight people are more prone to fatty liver disease. The increased levels of these enzymes are considered as an indicator of liver damage. Therefore, according to our results, exhausting aerobic exercise can be a more appropriate exercise for those with extra weight.

 

Acknowledgements

This research is part of a master thesis (Code of Ethics: Ir.Medilam.Rec.1395.192 and Clinical trial code: IRCT201104246178N1). The authors thank all the professors and students who helped to complete this study.   

 

Conflicts of Interest

Authors declared no conflict of interests.