Participants in group (A) received PIR for upper trapezius and sternocleidomastoid muscles. the therapist moved the subject's head into the position that put each muscle in stretch, once resistance/ barrier was felt, that position was held and subjects were asked to isometrically contract the target muscle with 20% of maximal contraction for 5 sec against mild resistance from the therapist, relax for 5 sec followed by passive stretch until reaching a new barrier for 30 sec, 3 repetitions for each muscle, 3sessions /week over a period of 4 weeks . In addition to the program designed for control group.
The treatment protocol was designed based on the assumption that the targeted muscles are the most shortened muscles in FHP.
PIR for upper trapezius The patient sat on a stool in an erect position. The therapist stood behind the patient with one hand on the patient's ipsilateral shoulder for stabilization, while the other was on the side of the patient's head. The patient's head was moved to flexion, lateral bending to the opposite side and rotation to the same side of the stretched muscle. The ipsilateral hand pushed the shoulder inferiorly to lengthen the muscle until the restrictive barrier was met, then we asked the patients to raise the shoulder against the hand isometrically then gently stretch the muscle until meeting a new barrier.
PIR for upper trapezius PIR for Sternocleidomastoid The patient sat on a stool in an erect position. The therapist stood behind the patient with her forearm on the patient's ipsilateral shoulder for stabilization, while the hands surrounded the patient's head. The head moved into lateral flexion away from the side of the involvement, rotation to the side of involvement, extension of the lower cervical spine and flexion of upper cervical spine to meet the restrictive barrier. The patient was instructed to push forward against the therapist's hand isometrically, and then gently stretch the muscle until meeting a new barrier.
Group (B) Participants in group (B) received static stretching exercise for upper trapezius and sternocleidomastoid .
Repetitions: 3times/day, 3days/week over a period of 4 weeks, in addition to strengthening exercises of deep cervical flexors and scapular retractor muscles, 3sets of 12 repetitions with 6 sec hold. In addition to postural advices Strengthening of deep cervical flexor muscles Each participant was instructed to sit with his arms relaxed at the side. The area above the lip and under the nose was lightly touched and the patient was asked to tuck his head down and in. The correct movement of tucking the chin in and straightening the spine were verbally reinforced. From sitting position, the patient was asked to tuck chin so that ears were in line with the tip of shoulders.
Strengthening of the scapular retractor muscles The participant sat on a chair without back support. The movement of the medial border of the scapula was gently resisted and the subject pinch them together "retraction". The subject was asked to imagine "holding a quarter between both the shoulder blades". Instructing each subject not to extend the shoulders or elevate the scapulae. The participant then stranded with his hands grasped together behind the lower back (this activity cause scapular adduction). The patient is instructed to adduct scapula and to hold the adducted position with both arms lowered downwards.
Postural education
• Postural advice They were advised that they should not sleep on a foam rubber pillow; should use a chair with proper back support and an arm rest of an appropriate height to provide elbow support while working at a keyboard and computer; should avoid leaning forward toward the screen of a computer or on a desk while writing for a prolonged period; and should avoid prolonged conversation on a telephone while holding the receiver by tilting the neck. Furthermore, the participants were advised to relieve muscle tension after every 20-30 minutes of work by getting up; stretching the arm, shoulder, neck, and back muscles; and walking to turn off the buzzer and reset the timer. They should either avoid prolonged carrying of a bag on any one side of the shoulder or balance the hanging weight of the bag on both sides of the shoulder.
