Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Research Protocol
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : YK01 - YK03 Full Version

Effect of Deep Cervical Flexor versus Core Stability Exercises on Range of Motion and Function in Individuals with Forward Head Posture-A Research Protocol

Published: March 1, 2023 | DOI:
Sakshi Padmawar, Deepali Patil

1. Resident, Department of Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 2. Associate Professor, Department of Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.

Correspondence Address :
Deepali Patil,
Associate Professor, Department of Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.


Introduction: The human spine forms cervical and lumbar lordosis and thoracic kyphosis when it is aligned in the sagittal plane against a vertical reference. When the head protrudes forward from the sagittal plane and appears to be in front of the body, it is called Forward Head Posture (FHP). The atlantooccipital joint and upper cervical vertebrae extend, whereas the lower cervical and upper thoracic vertebrae flex. FHP puts more strain on the neck causing problems with the musculoskeletal, neurological, and respiratory systems. The Deep Cervical Flexor (DCF) muscles have been revealed to have an important role in the cervical spine’s support and strengthening. FHP is one of the most typical incorrect postures that has increased in popularity recently.

Aim: To compare the impact of Core Stability Exercises (CSE) to DCF exercises on people who have a FHP.

Materials and Methods: In this interventional comparative study, a total of 70 patients with FHP and neck pain will be included with Craniovertebral Angle (CVA) less than 50o. They will be divided into two equal groups. After a warm-up, Group A will receive DCF exercises while Group B will receive CSE for four weeks, and pain, range, and function will be assessed at the beginning, after two weeks, and after four weeks of intervention. Pain will be assessed by the Visual Analogue Scale (VAS), range will be evaluated with a goniometer, and function will be assessed by Neck Disability Index (NDI). The statistical tests used will be Chi-square test and the Student t-test.

Expected Outcome: It is hypothesised that DCF exercises will prove to be successful in improving the ROM and function in individuals aged between 20-40 years with FHP.

Conclusion: The conclusion will be drawn based on the effect of both the techniques on pain, range, and function in individuals with FHP which will help patients and the therapist in a better approach to rehabilitation.


Core strength, Craniovertebral angle, Deep cervical muscles, Rehabilitation

When the human spine is aligned against a vertical reference in the sagittal plane, it creates three curves, the cervical and lumbar lordosis being the posteriorly concave portions and thoracic kyphosis being the anteriorly concave portion. These spinal curves are a compensating arrangement of spinal segments that sustain the body with the least amount of stress and energy consumption possible. The cervical spine’s function is to counterbalance the head against gravity’s force (1),(2). The most frequent postural deformity is FHP, which occurs when the head protrudes forward from the sagittal plane and appears to be in front of the body. The atlanto-occipital joint and upper cervical vertebrae extend, whereas the lower cervical and upper thoracic vertebrae flex (3).

A key component in developing incorrect head and neck posture is a lack of awareness while functioning. Poor head posture is thought to be inefficient because it increases the antigravity strain on cervical tissues, causing aberrant and compensatory activity which results in pain (3). FHP puts more strain on the neck, causing problems with the musculoskeletal, neurological, and respiratory systems. These modifications lead to prolonged and excessive strain on the muscles, fascia, and nerves of the neck and shoulders. Muscle shortening and elongation as a result of muscular imbalance causes many bodily components to malfunction. Prolonged FHP has been linked to a reduction in the number of sarcomeres as well as muscle fibre shortening, both of which can impact muscular contraction (4). Occupation and habits are two factors that contribute to this posture in modern individuals, and in most cases, except for the occupational element, are mostly impacted by the habit of using electronic devices. Even carrying a backpack causes poor posture in the body. With a reported incidence of 73%, this postural abnormality is common in people of all ages (5).

Given the relationship between FHP in standing and a lack of abdominal muscle control, which exacerbates thoracic kyphosis, it seems sensible to think that implementing a training program to enhance spinal realignment might help FHP. Inactive individuals can benefit from core muscle training programs to address FHP (6). Core stability regimens, on the other hand, are likely to reduce the percentage of muscle activity necessary for optimal posture maintenance and to reduce muscular fatigue in those muscles (6).

Adults with increased FHP have been reported to have poor neck flexor and extensor muscle function. Lower cervical flexion and extension, as well as posterior muscular stiffness and anterior cervical muscle weakening and lengthening, are all possible symptoms of FHP (7). It has been determined that the DCF muscles play a crucial role in the cervical spine’s stability (7).

In recent years, people have been adopting a sedentary lifestyle leading to bad posture. This can give some major complications in chronic stages. A lack of abdominal muscle control has been linked to attaining FHP. To reduce and prevent this posture, CSE plays a major role (6).

As no study comparing the impact of Deep Cervical Flexor Exercises (DCFE) and CSE and CSE on function and Range Of Motion (ROM) in individuals has been found; there is a strong need to perform a study to evaluate the same. This study aims to investigate the impact of DCFs on core stability in individuals with a FHP.

Material and Methods

The present research protocol is presented for an interventional comparative study which will be conducted in the Outpatient Department of Ravi Nair Physiotherapy College and AVBRH Sawangi, Wardha, Maharashtra, India from May 2022-May 2023 on individuals with FHP. The Ethical approval from the Institutional Ethical Committee of Datta Meghe Institute of Medical Sciences was received in April 2022 and we have registered with the Clinical Trial Registry India (CTRI)-CTRI/2022/08/044588.

Inclusion criteria: Healthy individuals aged between 20-40 years with either gender having CVA less than 50 degrees will be included in this study.

Exclusion criteria: Individuals who have migraine or cervicogenic headache or people who have undergone any surgery involving the spine or with injuries or history of fracture, conditions of the shoulder girdle, spine, trunk, and people who will refuse to participate will be excluded.

Sample size calculation: The participants enrolled in group A will be 35 and in group B will be 35 Total N=70. The following formula have been used to calculate the sample size;

n=(2?+2β)2(δ12+δ221K)/ Δ2

Zα is the level of significance at 5% that is 95%
Confidence interval=1.96
Zβ is the power of test =80%=0.84
δ 1=SD of past t/t VAS in experimental group=1.39 (7)
δ 2=SD of past t/t VAS in control group=1.58 (7)
Δ=Difference between 2 means

n=(1.96+0.84)2(1.392+1.5821K)/ Δ2
= 34.71=35 patients are needed in each group

Individuals who will be visiting physiotherapy OPD in Acharya Vinoba Bhave Rural Hospital and Ravi Nair Physiotherapy College with complaints of neck pain and who will fulfill the inclusion criteria will be included. We will assess the other undiagnosed individuals with FHP and include them in the study.

Study Procedure

All the participants will complete the intervention four weeks after their enrollment in the study. The evaluations will be taken on the first day of the visit, in the 2nd week, and before their last session which is the 4th week. The research coordinator and the lead investigator will distribute the people randomly according to simple random sampling technique.

The participants will be given a thorough description of the technique, and their informed consent will be obtained. The study will cover all people who are willing to participate. Participants will be screened by measuring the CVA (A horizontal line going through the C7 spinous process and a line connecting the midway of the tragus of the ear to the skin above the C7 spinous process forms the CVA) (8). The NDI, (a 10-item questionnaire that assesses the level of neck pain-related disability as indicated by the patient) will be used to evaluate function (9), and VAS will be used to assess neck pain. In standing, a goniometer will be used to assess ROM. All of the subjects will be categorised into two groups, with 35 participants in each group. The exercise program will be performed under the supervision of the researcher (Table/Fig 1).

Intervention and Intervention Design

Warm-up session: Both groups will complete a 10-minute warm-up session. The exercises will be repeated twice for a total of two sets of 10 repetitions. There will be a 10-second break between each set.

The session will include:

1. Upper trapezius stretching
2. Seated row
3. Gentle neck ROM which will include neck flexion, extension, and rotation.

Group A (DCFE): They will receive the DCFE for four weeks, 30 minutes each day, five days per week.

They will be instructed to complete three sets with 15 repetitions each.

1. A delicate nod of the head as if to indicate “yes”.
2. Chin tucks in supine lying.
3. Neck lateral bending with chin tucked (right and left)
4. Neck isometrics

Group B Core Stability Exercises (CSE): For four weeks, group B will be receiving CSE for 30 minutes each day, five days a week. They will be given three sets of 15 repetitions each.

1. Bridging
2. Plank
3. Bird dog exercise.
4. Hip extension in quadruped.

Outcome measures

Primary outcome measures: ROM will be assessed by a goniometer (10), CVA (11),(12).

Secondary outcome measure: Visual Analogue Scale (VAS) will be used for scoring their pain (13). NDI will be used for assessing the function (9).

Under the supervision of the lead investigators, data will be collected and reported at baseline, in the 2nd week and the 4th week after the session is completed from May 2022 to May 2023. The documentation will be thoroughly examined for accuracy. The Excel spreadsheet will be sent to a blinded statistician who will do the appropriate research after the study is completed.

Statistical Analysis

The data obtained will be written down and then organised in a tabular style. It will be scrutinised with the help of Statistical Package for Social Sciences (SPSS) 27.0, and Graphpad Prism 7.0V, and the statistical methods used will be Chi-square test and Student t-test.

Expected Outcome

The study results are expected to establish DCF exercises as more efficient in improving ROM and function in patients with FHP.


In general, FHP shortens the extensors of the neck, such as the splenii, upper trapezius, and SCM muscles, while lengthening and weakening the cervical flexors (3). According to research, when performance is compromised, the balance between the neck’s posterior stabilisers and the DCF is thrown off, which makes it difficult to maintain normal alignment and posture. This loss of alignment can then induce cervical impairment (14). The goal of the study is to analyse the efficacy of DCFE and CSE on ROM and function in people with FHP.

In previous studies, reduced CVA and cervical flexion range were predictors of cervical discomfort (4),(6). The exercises used are proven to be effective individually and in other age groups. Therefore, the comparison between these exercise programs in healthy individuals will be seen in this study. A warm-up session will activate the muscles and enhance the performance of both groups equally without altering the results.

A study conducted in 2021 by Esmaeili Z et al., compared the effect of CSE and functional corrective exercises on 14-16-year-old females resulting in a substantial effect on postural correction and a combination of exercises (Functional corrective exercises+CSE) considerably improved FHP when compared to each other (6). A systematic review done by Mahmoud NF et al., stated that age played an important role in the relation between neck pain and FHP. Also, FHP was increased in individuals with neck pain (15). The rationale behind DCF training as a treatment for FHP is that DCF has a significant postural role in sustaining and straightening cervical lordosis. Retraining these muscles has been shown to reduce neck symptoms and improve the ability to maintain an upright posture of the cervical spine. Improved ability in holding an upright posture of the cervical spine during the functional task of sitting was due to the high endurance of DCF muscles (16). Our findings could help healthcare professionals determine a patient’s functional condition. To avoid any disparities in recovery time between the two groups, both would have the same treatment duration.


A conclusion will be made on which therapeutic strategy DCFE or CSE is superior after the study is completed. The study’s findings will give information on DCFE’s efficacy in FHP. If this experiment is a success, individuals with FHP will be able to increase their ROM and function.


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Esmaeili Z, Hesar NGZ, Firouzjah EMAN, Roshani S. Comparing the effect of functional corrective exercises versus core stability exercises and a combined program on forward head posture and kyphosis in female adolescence. Journal of Rehabilitation Sciences and Research. 2021;8(2):62-68.
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Begum MR, Hossain MA. Validity and reliability of Visual Analogue Scale (VAS) for pain measurement. J Med Case Rep Rev. 2019 [cited 2022 Sep 25];2(11). Available from:
Kang DY. Deep cervical flexor training with a pressure biofeedback unit is an effective method for maintaining neck mobility and muscular endurance in college students with forward head posture. J Phys Ther Sci. 2015;27(10):3207-10. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2023/58905.17534

Date of Submission: Jul 05, 2022
Date of Peer Review: Sep 06, 2022
Date of Acceptance: Nov 08, 2022
Date of Publishing: Mar 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jul 06, 2022
• Manual Googling: Oct 11, 2022
• iThenticate Software: Nov 07, 2022 (17%)

ETYMOLOGY: Author Origin

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