Comparative Effects of Reverse Natural Apophyseal Glides Versus Sustained Natural Apophyseal Glides in Patients With Upper Cross Syndrome

Upper Cross Syndrome UCS is characterized by a cross pattern of muscular imbalance involving tightness of the upper trapezius, levator scapulae, and pectoral muscles, with weakness of the deep neck flexors, rhomboids, serratus anterior, middle trapezius, and lower trapezius. These imbalances contribute to forward head posture, rounded shoulders, and increased thoracic kyphosis, while also affecting scapulothoracic rhythm and cervical biomechanics. To address these impairments, both groups will receive manual therapy targeting C6 to T2 along with an identical conventional physiotherapy protocol for 4 weeks.Group A will receive Reverse Natural Apophyseal Glides. Participants will sit comfortably while the therapist applies Reverse Natural Apophyseal Glides to the lower cervical and upper thoracic segments C6 to T2. The therapist will apply small amplitude rhythmic oscillations at the end range of the facet joints. On day 1, 3 oscillations will be performed in

1 set. For the remaining days, the dosage will progress to 10 oscillations, 3 sets. Group B will receive Sustained Natural Apophyseal Glides. Participants will sit upright while the therapist stands behind them. The therapist will stabilize the desired spinous process using the medial border of one thumb, reinforced by the pulp of the opposite thumb, with the fingers positioned comfortably around the mandible. The participant will actively perform cervical extension while the therapist maintains a posterior to anterior glide on the selected spinous process toward the participant's eyes throughout the movement. The participant will perform end range overpressure. On day 1, 3 repetitions will be performed in 1 set, progressing to 10 repetitions, 3 sets for the remaining days. For both groups, the conventional protocol will begin with a hot pack applied to the posterior cervical and upper thoracic region for 10 minutes in prone lying. Stretching will include the pectoralis, upper trapezius, and levator scapulae, with each stretch held for 10 seconds for 10 repetitions, 3 sets, with a 5 second interval between repetitions. Strengthening will include deep cervical flexor activation through chin tucks and scapular stabilizers targeting the middle trapezius, lower trapezius, serratus anterior and rhomboids. On day 1-3, supine foam roller exercises performed at three shoulder abduction angles. From days 4-6, side lying external rotation and forward flexion exercises will be performed. From days 7-9, prone V, T, and W exercises will be performed. From days 10-12, standing diagonal flexion and military press exercises will be performed. Each strengthening exercise will be performed for 10 repetitions, 3 sets, with a 10 second hold for each repetition. This progressive protocol will provide increasing postural and scapular stabilization demands while maintaining the same conventional treatment across both groups, allowing the specific effects of Reverse Natural Apophyseal Glides and Sustained Natural Apophyseal Glides to be compared.