The Effect of Eight Weeks of Iyengar Yoga With an Emphasis on Spine and Shoulder Exercises on the Upper Cross Syndrome in Middle-aged Women
Abstract
Introduction: Upper Crossed Syndrome (UCS) is a combination of forward head, rounded shoulder, and hyperkyphosis deformities. Yoga is a non-competitive physical exercise with the potential to correct postural imbalances in the human body. Iyengar yoga is a form of Hatha yoga.
Materials and Methods: The purpose of present study was to evaluate the effect of Iyengar yoga with an emphasis on spine and shoulder exercises on the UCS in middle-aged women. In this quasi-experimental applied research, 15 subjects were purposefully recruited out of middle-aged women affected with UCS. The participants performed Iyengar yoga exercises with an emphasis on the spine and shoulder. The photogrammetry method was used to measure UCS.
Results: At the end of 8 weeks exercises, there was a significant increase in the cervical (P<0.001) and shoulder angles (P<0.005), and a significant decrease in thoracic flexion angle (P<0.001).
Conclusion: All relevant coaches and therapists are recommended considering Iyengar yoga as an alternative for training programs in middle-aged women affected by UCS.
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2. Peterson J. Teaching Pilates for postural faults, illness and injury: A practical guide, 1st edition. Philadelphia: Butterworth Hernemann Elsevier; 2009.
3. Peterson-Kendall F, Kendall-McCreary E, Geise-Provance P, McIntyre-Rodgers M, Romani W. Muscles testing and function with posture and pain. Philadelphia: Lippincott Williams & Wilkins, Ltd; 2005.
4. Page P, Frank C, Lardner R. Assessment and treatment of muscle imbalance: The Janda approach, 1st edition. Human Kinetics, Inc.; 2009.
5. Thigpen CA, Padua DA, Michener LA, Guskiewicz K, Giuliani C, Keener JD, et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. Journal of Electromyography and Kinesiology. 2010; 20(4):701-9. [DOI:10.1016/j.jelekin.2009.12.003] [PMID]
6. Ruivo RM, Pezarat-Correia P, Carita AI. Effects of a resistance and stretching training program on forward head and protracted shoulder posture in adolescents. Journal of Manipulative and Physiological Therapeutics. 2017; 40(1):1-10. [DOI:10.1016/j.jmpt.2016.10.005] [PMID]
7. Thacker D, Jameson J, Baker J, Divine J, Unfried A. Management of upper cross syndrome through the use of active release technique and prescribed exercises [PhD. dissertation]. United States: Logan College of Chiropractic. 2011. https://pdfs.semanticscholar.org/ed40/d7b401417169d724af4770d5cc8812bf9be0.pdf
8. Clark M, Lucett S. NASM essentials of corrective exercise training. Philadelphia: Lippincott Williams & Wilkins; 2010.
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10. Yoo WG, Yi CH, Kim MH. Effects of a ball-backrest chair on the muscles associated with upper crossed syndrome when working at a VDT. Work. 2007; 29(3):239-44. https://yonsei.pure.elsevier.com/en/publications/effects-of-a-ball-backrest-chair-on-the-muscles-associated-with-u
11. Mujawar JC, Sagar JH. Prevalence of upper cross syndrome in laundry workers. Indian Journal of Occupational and Environmental Medicine. 2019; 23(1):54-6. [DOI:10.4103/ijoem.IJOEM_169_18] [PMID] [PMCID]
12. Verma SL, Shaikh J, Mahato RK, Sheth MS. Prevalence of forward head posture among 12-16 year old school going students: A cross sectional study. Applied Medical Research. 2018; 4(2):18-21. [DOI:10.5455/amr.20180805064752]
13. Gh ME, Alilou A, Ghafurinia S, Fereydounnia S. Prevalence of faulty posture in children and youth from a rural region in Iran. Biomedical Human Kinetics. 2012; 4(1):121-6. [DOI:10.2478/v10101-012-0023-z]
14. Vakili L, Halabchi F, Mansournia MA, Khami MR, Irandoost S, Alizadeh Z. Prevalence of common postural disorders among academic dental staff. Asian Journal of Sports Medicine. 2016; 7(2):e29631. [DOI:10.5812/asjsm.29631] [PMID] [PMCID]
15. Batistão MV, Moreira RdFC, Coury HJCG, Salasar LEB, Sato Td O. Prevalence of postural deviations and associated factors in children and adolescents: A cross-sectional study. Fisioterapia em Movimento. 2016; 29(4):777-86. [DOI:10.1590/1980-5918.029.004.ao14]
16. Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. International Journal of Sports Physical Therapy. 2011; 6(1):51-8. [PMID] [PMCID]
17. Sahrmann S, Azevedo DC, Van Dillen L. Diagnosis and treatment of movement system impairment syndromes. Brazilian Journal of Physical Therapy. 2017; 21(6):391-9. [DOI: 10.1016/j.bjpt.2017.08.001]
18. Gillani SN, Qurat -Ul- Ain, Rehman SU, Masood T. Effects of eccentric muscle energy technique versus static stretching exercises in the management of cervical dysfunction in upper cross syndrome: A randomized control trial. The Journal of the Pakistan Medical Association. 2020; 70(3):394-8. [DOI:10.5455/JPMA.300417] [PMID]
19. Sengupta P. Health impacts of yoga and pranayama: A state-of-the-art review. International Journal of Preventive Medicine. 2012; 3(7):444-58. [PMID] [PMCID]
20. Sharan D, Manjula M, Urmi D, Ajeesh P. Effect of yoga on the Myofascial Pain Syndrome of neck. International Journal of Yoga. 2014; 7(1):54-9. [DOI:10.4103/0973-6131.123486] [PMID] [PMCID]
21. Amin DJ, Goodman M. The effects of selected asanas in Iyengar yoga on flexibility: Pilot study. Journal of Bodywork and Movement Therapies. 2014; 18(3):399-404. [DOI:10.1016/j.jbmt.2013.11.008] [PMID]
22. Grabara M, Szopa J. Effects of hatha yoga exercises on spine flexibility in women over 50 years old. Journal of Physical Therapy Science. 2015; 27(2):361-5. [DOI:10.1589/jpts.27.361] [PMID] [PMCID]
23. Greendale GA, Huang MH, Karlamangla AS, Seeger L, Crawford S. Yoga decreases kyphosis in senior women and men with adult‐onset hyperkyphosis: Results of a randomized controlled trial. Journal of the American Geriatrics Society. 2009; 57(9):1569-79. [DOI:10.1111/j.1532-5415.2009.02391.x] [PMID] [PMCID]
24. Grabara M. Effects of 8-months yoga training on shaping the spine in people over 55. Biomedical Human Kinetics. 2013; 5(1):59-64. [DOI:10.2478/bhk-2013-0009]
25. Grabara M, Szopa J. Effects of hatha yoga on the shaping of the antero-posterior curvature of the spine. Human Movement. 2011; 12(3):259-63. [DOI:10.2478/v10038-011-0028-4]
26. Greendale GA, McDivit A, Carpenter A, Seeger L, Huang M-H. Yoga for women with hyperkyphosis: Results of a pilot study. American Journal of Public Health. 2002; 92(10):1611-4. [DOI:10.2105/AJPH.92.10.1611] [PMID] [PMCID]
27. Savić K, Pfau D, Skorić S, Pfau J, Spasojević N. The effect of Hatha yoga on poor posture in children and the psychophysiologic condition in adults. Medicinski Pregled. 1990; 43(5-6):268-72. [PMID]
28. Hajihosseini E, Norasteh A, Shamsi A, Daneshmandi H. The effects of strengthening, stretching and comprehensive exercises on forward shoulder posture correction. Physical Treatments-Specific Physical Therapy Journal. 2014; 4(3):123-32.
29. Kang J-I, Choi H-H, Jeong D-K, Choi H, Moon Y-J, Park J-S. Effect of scapular stabilization exercise on neck alignment and muscle activity in patients with forward head posture. Journal of Physical Therapy Science. 2018; 30(6):804-8. [DOI:10.1589/jpts.30.804] [PMID] [PMCID]
30. Seidi F, Rajabi R, Ebrahimi I, Alizadeh MH, Minoonejad H. The efficiency of corrective exercise interventions on thoracic hyper-kyphosis angle. Journal of Back and Musculoskeletal Rehabilitation. 2014; 27(1):7-16. [DOI:10.3233/BMR-130411] [PMID]
31. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007; 39(2):175-91. [DOI:10.3758/BF03193146] [PMID]
32. Ruivo RM, Pezarat-Correia P, Carita AI. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Brazilian Journal of Physical Therapy. 2014; 18(4):364-71. [DOI:10.1590/bjpt-rbf.2014.0027] [PMID] [PMCID]
33. Rodrigues A, Romeiro C, Patrizzi L. Evaluation of thoracic kyphosis in older adult women with osteoporosis by means of computerized biophotogrammetry. Revista Brasileira de Fisioterapia. 2009; 13(3):205-9. [DOI:10.1590/S1413-35552009005000036]
34. Porto AB, Okazaki VHA. Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: A literature review. Journal of Bodywork and Movement Therapies. 2017; 21(4):986-94. [DOI:10.1016/j.jbmt.2017.01.008] [PMID]
35. Watson AWS. Procedure for the production of high quality photographs suitable for the recording and evaluation of posture. Rev Fisioter Univ São Paulo. 1998; 5(1).
36. Puig-Diví A, Padullés-Riu JM, Busquets-Faciaben A, Padullés-Chando X, Escalona-Marfil C, Marcos-Ruiz D. Validity and reliability of the kinovea program in obtaining angular and distance dimensions. Preprints 2017; 2017100042. [DOI:10.20944/preprints201710.0042.v1]
37. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy. 2005; 35(2):72-87. [DOI:10.2519/jospt.2005.35.2.72] [PMID]
38. Singla D, Veqar Z, Hussain ME. Photogrammetric assessment of upper body posture using postural angles: A literature review. Journal of Chiropractic Medicine. 2017; 16(2):131-8. [DOI:10.1016/j.jcm.2017.01.005] [PMID] [PMCID]
39. Rajalaxmi V, Paul J, Nithya M, Lekha SC, Likitha B. Effectiveness of three dimensional approach of schroth method and yoga on pulmonary function test and posture in upper crossed syndrome with neck Pain-A double blinded study. Research Journal of Pharmacy and Technology. 2018; 11(5):1835-9. [DOI:10.5958/0974-360X.2018.00341.4]
40. Selvaganapathy K, Rajappan R, Dee TH. The effect of smartphone addiction on craniovertebral angle and depression status among university students. International Journal of Intagrative Medical Sciences. 2017; 4(5):537-42. [DOI:10.16965/ijims.2017.118]
41. Ghiasinezhad S, Hadadnezhad M, Letafatkar A. The effects of eight weeks of yoga training on motor control, proprioception and forward head angle among girls diagnosed with forward head posture. International Journal of Medical Research & Health Sciences. 2016; 5(11):40-6.
42. Harman K, Hubley-Kozey CL, Butler H. Effectiveness of an exercise program to improve forward head posture in normal adults: A randomized, controlled 10-week trial. Journal of Manual & Manipulative Therapy. 2005; 13(3):163-76. [DOI:10.1179/106698105790824888]
43. Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine. 2010; 44(5):376-81. [DOI:10.1136/bjsm.2009.066837] [PMID]
44. Park H-C, Kim Y-S, Seok S-H, Lee S-K. The effect of complex training on the children with all of the deformities including forward head, rounded shoulder posture, and lumbar lordosis. Journal of Exercise Rehabilitation. 2014; 10(3):172-5. [DOI:10.12965/jer.140113] [PMID] [PMCID]
45. Wong CK, Coleman D, Song J, Wright D. The effects of manual treatment on rounded-shoulder posture, and associated muscle strength. Journal of Bodywork and Movement Therapies. 2010; 14(4):326-33. [DOI:10.1016/j.jbmt.2009.05.001] [PMID]
2. Peterson J. Teaching Pilates for postural faults, illness and injury: A practical guide, 1st edition. Philadelphia: Butterworth Hernemann Elsevier; 2009.
3. Peterson-Kendall F, Kendall-McCreary E, Geise-Provance P, McIntyre-Rodgers M, Romani W. Muscles testing and function with posture and pain. Philadelphia: Lippincott Williams & Wilkins, Ltd; 2005.
4. Page P, Frank C, Lardner R. Assessment and treatment of muscle imbalance: The Janda approach, 1st edition. Human Kinetics, Inc.; 2009.
5. Thigpen CA, Padua DA, Michener LA, Guskiewicz K, Giuliani C, Keener JD, et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. Journal of Electromyography and Kinesiology. 2010; 20(4):701-9. [DOI:10.1016/j.jelekin.2009.12.003] [PMID]
6. Ruivo RM, Pezarat-Correia P, Carita AI. Effects of a resistance and stretching training program on forward head and protracted shoulder posture in adolescents. Journal of Manipulative and Physiological Therapeutics. 2017; 40(1):1-10. [DOI:10.1016/j.jmpt.2016.10.005] [PMID]
7. Thacker D, Jameson J, Baker J, Divine J, Unfried A. Management of upper cross syndrome through the use of active release technique and prescribed exercises [PhD. dissertation]. United States: Logan College of Chiropractic. 2011. https://pdfs.semanticscholar.org/ed40/d7b401417169d724af4770d5cc8812bf9be0.pdf
8. Clark M, Lucett S. NASM essentials of corrective exercise training. Philadelphia: Lippincott Williams & Wilkins; 2010.
9. Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. Journal of Manipulative and Physiological Therapeutics. 2004; 27(6):414-20. [DOI:10.1016/j.jmpt.2004.05.007] [PMID]
10. Yoo WG, Yi CH, Kim MH. Effects of a ball-backrest chair on the muscles associated with upper crossed syndrome when working at a VDT. Work. 2007; 29(3):239-44. https://yonsei.pure.elsevier.com/en/publications/effects-of-a-ball-backrest-chair-on-the-muscles-associated-with-u
11. Mujawar JC, Sagar JH. Prevalence of upper cross syndrome in laundry workers. Indian Journal of Occupational and Environmental Medicine. 2019; 23(1):54-6. [DOI:10.4103/ijoem.IJOEM_169_18] [PMID] [PMCID]
12. Verma SL, Shaikh J, Mahato RK, Sheth MS. Prevalence of forward head posture among 12-16 year old school going students: A cross sectional study. Applied Medical Research. 2018; 4(2):18-21. [DOI:10.5455/amr.20180805064752]
13. Gh ME, Alilou A, Ghafurinia S, Fereydounnia S. Prevalence of faulty posture in children and youth from a rural region in Iran. Biomedical Human Kinetics. 2012; 4(1):121-6. [DOI:10.2478/v10101-012-0023-z]
14. Vakili L, Halabchi F, Mansournia MA, Khami MR, Irandoost S, Alizadeh Z. Prevalence of common postural disorders among academic dental staff. Asian Journal of Sports Medicine. 2016; 7(2):e29631. [DOI:10.5812/asjsm.29631] [PMID] [PMCID]
15. Batistão MV, Moreira RdFC, Coury HJCG, Salasar LEB, Sato Td O. Prevalence of postural deviations and associated factors in children and adolescents: A cross-sectional study. Fisioterapia em Movimento. 2016; 29(4):777-86. [DOI:10.1590/1980-5918.029.004.ao14]
16. Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. International Journal of Sports Physical Therapy. 2011; 6(1):51-8. [PMID] [PMCID]
17. Sahrmann S, Azevedo DC, Van Dillen L. Diagnosis and treatment of movement system impairment syndromes. Brazilian Journal of Physical Therapy. 2017; 21(6):391-9. [DOI: 10.1016/j.bjpt.2017.08.001]
18. Gillani SN, Qurat -Ul- Ain, Rehman SU, Masood T. Effects of eccentric muscle energy technique versus static stretching exercises in the management of cervical dysfunction in upper cross syndrome: A randomized control trial. The Journal of the Pakistan Medical Association. 2020; 70(3):394-8. [DOI:10.5455/JPMA.300417] [PMID]
19. Sengupta P. Health impacts of yoga and pranayama: A state-of-the-art review. International Journal of Preventive Medicine. 2012; 3(7):444-58. [PMID] [PMCID]
20. Sharan D, Manjula M, Urmi D, Ajeesh P. Effect of yoga on the Myofascial Pain Syndrome of neck. International Journal of Yoga. 2014; 7(1):54-9. [DOI:10.4103/0973-6131.123486] [PMID] [PMCID]
21. Amin DJ, Goodman M. The effects of selected asanas in Iyengar yoga on flexibility: Pilot study. Journal of Bodywork and Movement Therapies. 2014; 18(3):399-404. [DOI:10.1016/j.jbmt.2013.11.008] [PMID]
22. Grabara M, Szopa J. Effects of hatha yoga exercises on spine flexibility in women over 50 years old. Journal of Physical Therapy Science. 2015; 27(2):361-5. [DOI:10.1589/jpts.27.361] [PMID] [PMCID]
23. Greendale GA, Huang MH, Karlamangla AS, Seeger L, Crawford S. Yoga decreases kyphosis in senior women and men with adult‐onset hyperkyphosis: Results of a randomized controlled trial. Journal of the American Geriatrics Society. 2009; 57(9):1569-79. [DOI:10.1111/j.1532-5415.2009.02391.x] [PMID] [PMCID]
24. Grabara M. Effects of 8-months yoga training on shaping the spine in people over 55. Biomedical Human Kinetics. 2013; 5(1):59-64. [DOI:10.2478/bhk-2013-0009]
25. Grabara M, Szopa J. Effects of hatha yoga on the shaping of the antero-posterior curvature of the spine. Human Movement. 2011; 12(3):259-63. [DOI:10.2478/v10038-011-0028-4]
26. Greendale GA, McDivit A, Carpenter A, Seeger L, Huang M-H. Yoga for women with hyperkyphosis: Results of a pilot study. American Journal of Public Health. 2002; 92(10):1611-4. [DOI:10.2105/AJPH.92.10.1611] [PMID] [PMCID]
27. Savić K, Pfau D, Skorić S, Pfau J, Spasojević N. The effect of Hatha yoga on poor posture in children and the psychophysiologic condition in adults. Medicinski Pregled. 1990; 43(5-6):268-72. [PMID]
28. Hajihosseini E, Norasteh A, Shamsi A, Daneshmandi H. The effects of strengthening, stretching and comprehensive exercises on forward shoulder posture correction. Physical Treatments-Specific Physical Therapy Journal. 2014; 4(3):123-32.
29. Kang J-I, Choi H-H, Jeong D-K, Choi H, Moon Y-J, Park J-S. Effect of scapular stabilization exercise on neck alignment and muscle activity in patients with forward head posture. Journal of Physical Therapy Science. 2018; 30(6):804-8. [DOI:10.1589/jpts.30.804] [PMID] [PMCID]
30. Seidi F, Rajabi R, Ebrahimi I, Alizadeh MH, Minoonejad H. The efficiency of corrective exercise interventions on thoracic hyper-kyphosis angle. Journal of Back and Musculoskeletal Rehabilitation. 2014; 27(1):7-16. [DOI:10.3233/BMR-130411] [PMID]
31. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007; 39(2):175-91. [DOI:10.3758/BF03193146] [PMID]
32. Ruivo RM, Pezarat-Correia P, Carita AI. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Brazilian Journal of Physical Therapy. 2014; 18(4):364-71. [DOI:10.1590/bjpt-rbf.2014.0027] [PMID] [PMCID]
33. Rodrigues A, Romeiro C, Patrizzi L. Evaluation of thoracic kyphosis in older adult women with osteoporosis by means of computerized biophotogrammetry. Revista Brasileira de Fisioterapia. 2009; 13(3):205-9. [DOI:10.1590/S1413-35552009005000036]
34. Porto AB, Okazaki VHA. Procedures of assessment on the quantification of thoracic kyphosis and lumbar lordosis by radiography and photogrammetry: A literature review. Journal of Bodywork and Movement Therapies. 2017; 21(4):986-94. [DOI:10.1016/j.jbmt.2017.01.008] [PMID]
35. Watson AWS. Procedure for the production of high quality photographs suitable for the recording and evaluation of posture. Rev Fisioter Univ São Paulo. 1998; 5(1).
36. Puig-Diví A, Padullés-Riu JM, Busquets-Faciaben A, Padullés-Chando X, Escalona-Marfil C, Marcos-Ruiz D. Validity and reliability of the kinovea program in obtaining angular and distance dimensions. Preprints 2017; 2017100042. [DOI:10.20944/preprints201710.0042.v1]
37. Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy. 2005; 35(2):72-87. [DOI:10.2519/jospt.2005.35.2.72] [PMID]
38. Singla D, Veqar Z, Hussain ME. Photogrammetric assessment of upper body posture using postural angles: A literature review. Journal of Chiropractic Medicine. 2017; 16(2):131-8. [DOI:10.1016/j.jcm.2017.01.005] [PMID] [PMCID]
39. Rajalaxmi V, Paul J, Nithya M, Lekha SC, Likitha B. Effectiveness of three dimensional approach of schroth method and yoga on pulmonary function test and posture in upper crossed syndrome with neck Pain-A double blinded study. Research Journal of Pharmacy and Technology. 2018; 11(5):1835-9. [DOI:10.5958/0974-360X.2018.00341.4]
40. Selvaganapathy K, Rajappan R, Dee TH. The effect of smartphone addiction on craniovertebral angle and depression status among university students. International Journal of Intagrative Medical Sciences. 2017; 4(5):537-42. [DOI:10.16965/ijims.2017.118]
41. Ghiasinezhad S, Hadadnezhad M, Letafatkar A. The effects of eight weeks of yoga training on motor control, proprioception and forward head angle among girls diagnosed with forward head posture. International Journal of Medical Research & Health Sciences. 2016; 5(11):40-6.
42. Harman K, Hubley-Kozey CL, Butler H. Effectiveness of an exercise program to improve forward head posture in normal adults: A randomized, controlled 10-week trial. Journal of Manual & Manipulative Therapy. 2005; 13(3):163-76. [DOI:10.1179/106698105790824888]
43. Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine. 2010; 44(5):376-81. [DOI:10.1136/bjsm.2009.066837] [PMID]
44. Park H-C, Kim Y-S, Seok S-H, Lee S-K. The effect of complex training on the children with all of the deformities including forward head, rounded shoulder posture, and lumbar lordosis. Journal of Exercise Rehabilitation. 2014; 10(3):172-5. [DOI:10.12965/jer.140113] [PMID] [PMCID]
45. Wong CK, Coleman D, Song J, Wright D. The effects of manual treatment on rounded-shoulder posture, and associated muscle strength. Journal of Bodywork and Movement Therapies. 2010; 14(4):326-33. [DOI:10.1016/j.jbmt.2009.05.001] [PMID]
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| Issue | Vol 14 No 3 (2020) | |
| Section | Research Article(s) | |
| DOI | https://doi.org/10.18502/jmr.v14i3.7714 | |
| Keywords | ||
| Iyengar Syndrome Exercise | ||
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How to Cite
1.
Sohrabi S, Rahimi M, Babaei-Mobarakeh M, Piri H. The Effect of Eight Weeks of Iyengar Yoga With an Emphasis on Spine and Shoulder Exercises on the Upper Cross Syndrome in Middle-aged Women. jmr. 2020;14(3):159-168.
