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Introduction
Depression and anxiety are among the most common psychiatric disorders [1]. Depression is one of the four major diseases in the world and the most common cause of disability caused by diseases [1]. About 121 million people in the world struggle with problems related to depression [2]. The prevalence of this disorder has been reported differently in different countries so that in Japan and China, the lowest prevalence of depression (6%) and in Brazil and New Zealand the highest prevalence of depression (20%), have been observed [3]. Based on assumptions, the main mechanisms of major depressive disorder include inflammation, disruption, and lack of coordination in hypothalamus function and neurotrophic elements, including neurotrophic factors derived from the brain [4]. Its specific symptoms include loss of energy and interests, low self-confidence, feelings of sadness and guilt, and changes in appetite and sleep patterns, which are associated with differences and similarities in men, women, children, and the elderly, which ultimately reduce the quality of life and the performance of the individuals [5]. One of the important long-term effects of depression is the body’s deviation from its normal state. People suffering from depression are in an isolated state for a long time; thus, their physical condition will be affected [6]. In this regard, people with depressive disorders have increased anterior tilt of the head, hyperkyphosis of the thoracic spine, and a heightened state of scapula abduction [7]. Postural deviations and abnormalities can result from factors, such as prolonged static postures, repetitive movements, muscular weaknesses in deep muscle groups, neuro-muscular control deficiencies, physical inactivity, or the inability of tissues to return to their initial state after activity [8]. One specific deviation affecting the upper quarter of the body is known as upper crossed syndrome [9]. In the upper crossed syndrome, which affects the neck and shoulder girdle, the posterior-superior muscles (levator scapula muscle and the upper part of the trapezius) and anterior chest (pectoralis major and minor), which are among the muscles of the tonic system, become tense. Meanwhile, the parallelogram muscles, which consist of the middle and lower trapezius, serratus anterior, and deep neck flexors, primarily fall under the phasic muscle system and tend to weaken [10]. This syndrome leads to widespread changes, such as head forward, increased cervical lordosis, dorsal kyphosis, rounded shoulders, shoulder abduction and winging, and reduced stability of the glenohumeral joint in the upper quarter of the body [9]. Disorders of the spine and the occurrence of the upper cross syndrome are associated with poor balance and reduced function, and any disorder in the spine affects the proper function of the deep receptors inside the ligaments and disrupts the sense of joint condition [11]. In other words, proprioceptive receptors are located in muscles, joints, and skin. Muscle receptors are thought to be most important in providing proprioceptive information [12]. The concentration of these receptors in the neck area and deep muscles is more than surface muscles. The occurrence of upper crossed syndrome abnormality changes the length of anterior and posterior neck muscles so that most of the superficial muscles are shortened and the deep muscles are lengthened and weakened, and these changes in muscle length and tension damage joint sense in the neck region [12]. Ha and Sung showed that the forward head position increases the absolute error of returning to a neutral position in returning from the full range of forward, backward, and side-to-side head flexion [13]. In the realm of corrective measures, therapeutic exercise or the utilization of corrective movements is a commonly employed approach for rectifying upper crossed syndrome deformities. Consequently, it can effectively enhance the perception of joint conditions in the neck region and improve overall performance. In the field of physical deformity correction, there are innovative methods, including corrective games and postural exercises tailored to specific deformities [14, 15]. Another noteworthy technique for addressing incorrect posture patterns is teaching proper posture and addressing bodily irregularities in daily activities, a method that has gained considerable attention recently [15]. Also, corrective games represent a novel approach to correction, holding significant value at the intersection of rehabilitation and psychological techniques in terms of education and therapeutic training. Corrective games utilize natural means of expression, such as play, to serve as a therapeutic method for individuals dealing with mental health issues, aiding them in managing their emotional pressures. Considering the enjoyment and compatibility of such movement activities with the physical and mental abnormalities of people suffering from depression, these games can increase their enthusiasm and interest in physical activity. They promote the coordinated development of various body organs and parts, establishing an appropriate length-tension relationship with muscles, and ultimately improving joint position sense and function in individuals with depression [16]. 
To date, there have been no studies investigating the identification and correction of upper limb misalignment, proprioceptive sensation in the neck region, and movement function in individuals with depression who have upper-cross syndrome. Therefore, the current research intended to compare the changes made in proprioceptive sensation in the neck region and upper limb function in patients with depression before and after the implementation of a program of selected corrective exercises. Given the importance of corrective exercises in preventing postural misalignments, improving upper extremity function, and proprioceptive sensation in the neck region for individuals with depression, and the existing research gap in this area, the researcher conducted the current study. 

Materials and Methods

Participants
The current quasi-experimental research followed a pre-test and post-test design. Based on the research topic, people suffering from depression with an age range of 18 to 40 years were introduced as the statistical population. Among them, 30 people were selected as the sample based on available sampling. G*Power software, version 3.1.9.4 was used to determine the sample size. Accordingly, 290 people were numbered at first and then, the sample size was estimated by the software. Even numbers were assigned to the experimental group and odd numbers to the control group. Finally, 15 people were considered as the experimental group and 15 people as the control group.

Procedures
Patients with forward head deformity (>46 degrees), kyphosis deformity (>42 degrees), and shoulder forward deformity (>52 degrees) were included in the study [10]. Other inclusion criteria were depression with a score between 19 and 27 [17]. The exclusion criteria were the problems related to articular disc destruction disorders, spinal cord problems, respiratory and cardiovascular problems, and no history of surgery in the upper and lower body. Also, cases, such as severe vision and hearing disorders, neurological diseases, the presence of orthopedic lesions in the upper and lower limbs, and injury in the training period or during sports activities were considered as exclusion criteria [10]. 
After coordinating with the officials and confirming their readiness, the researcher visited the Mental and Health Center of Hajar Hospital, located in Shahr-e Kord. Following the approval of the subscription by the Ethics Committee of the Sport Sciences Research Institute, the participants were randomly divided into two groups: An experimental group and a control group. This division was done by selecting numbers 1 and 2 from inside sealed envelopes. 
To evaluate the level of depression among the participants, Beck’s depression inventory (BDI) (1961) was used [17]. The BDI was initially prepared by Aaron T. Beck in the 1960s to measure and evaluate the presence or absence of depression as well as its severity in adolescents and adults. It was revised in 1971 and published in 1978 and comprises 21 questions, each with four response options (0-1-2-3). People marked the option that best expressed their feelings about their mental state during the week by checking the corresponding boxes. Out of these questions, 15 were related to mental and emotional states, while 6 pertained to the subjects’ physical states. The total score was calculated by adding together the scores from both the mental and physical sections. This total score could range from 0 to 63. Individuals who scored between 0 and 9 were categorized as not having depression. A score falling within the range of 10 to 15 indicated mild depression, while a score between 17 and 29 indicated moderate depression and a score above 30 indicated severe depression [17]. The validity and reliability of this questionnaire have been confirmed in previous studies, such as those conducted by Mark and Mendelson [17] Based on our research objective, people with moderate degrees of depression were included in the study.

Upper extremity function testing
The Y balance device was used to evaluate upper extremity function [18]. Gorman et al. (2012) reported an intra-rater coefficient of correlation (ICC) of 0.80-0.99 and an inter-examiner ICC of 1.00 [18]. This device consists of a fixed plate to which three rods are connected in three directions: internal, lower-external, and upper-external, positioned at angles of 120 degrees to each other. Each rod was marked in centimeters, and there was a moving indicator on each graded rod that the subject’s free hand pushed to achieve maximum reach distance. The subject first placed his non-dominant hand on the stationary plate for support and was placed in the Swedish swimming position. Then, he moved his dominant hand for the maximum reaching distance in the internal direction, immediately in the lower-external direction and then in the upper-external direction, and then, he returned to the initial position of the test. The subject tried all three directions three times and their average was calculated. For normalization, data were divided by upper extremity length. For the final score, the sum of the total scores divided by the body was multiplied by three and the obtained number was multiplied by 100 [18].

Cervical JPE testing
To evaluate the range of motion of the cervical region, the study by Lee et al. [19]. was modeled. To perform the assessment, the subject was placed in a sitting position on a chair placed on the floor so that the head was in a neutral position [20]. During the assessment, a mask was used over the subjects’ eyes to fix the movement of the head and neck area. The tester firmly placed the instrument on the subject’s head using a cloth. The north direction sign of the device was placed on the person’s shoulder [21]. Then, the device was calibrated in the same state. The validity and reliability of this device are between 0.62 and 0.91. To evaluate the range of motion, the device was placed on the head and the subject slowly moved his head in the direction of the tested target [21] and held this position for 3 seconds. Then, he/she returned the head to the first position [22]. Again, he moved the head towards the target, and then, the error level in the position of the neck region was evaluated in terms of degrees. The range of the cervical region was measured in flexion, extension, lateral, and medial rotation. Finally, each of the modes was evaluated three times and the average error of neck position sense was recorded. During the test, the patient received no feedback [23]. After the evaluations of variables in the pre-test, for eight weeks and three sessions per week, the experimental group performed selected corrective exercises (corrective exercises, postural correction training, and corrective games). During this period, the control group did not experience any training. Finally, after performing the selected corrective exercises, the mentioned variables were measured again in the post-test.
Selected corrective exercises: The functional and corrective exercises in this study were based on the agreement and opinion of the researchers, and their layout and design were based on Saharman’s corrective protocol. These exercises are the result of functional exercises, designed games, and exercises related to training how to correct body posture and remove wrong patterns, which were completed in eight weeks and three sessions every week. The exercises started with warming up for 10 minutes. The main exercise lasted 45 minutes and the cooling time at the end of the exercise was 10 minutes. The level of exercises progressed from simple to complex exercises from the beginning to the end of the training sessions. During training, the training load was added gradually based on the pattern of load increase. Also, the principles of individual characteristics were followed (Table 1). The rest period between each set was 45 seconds and the amount of rest between these types of exercises was 90 seconds due to high pressure [24] (Table 1).



Corrective games: In this study, corrective games were designed and used using previous studies [25, 26]. The content of these games was used to reduce and improve the mental and psychological condition of the subjects based on the improvement of spinal postural abnormalities and also because it was more of an entertainment aspect (Table 2).



Exercises to correct body deviations: In this section, because the subjects had postural abnormalities of the upper crossed syndrome, a postural correction program was considered for them in accordance with this type of abnormality. At the beginning of the exercise, they were talked about being in a normal position, and their postural mistakes were corrected, and the subjects were warned to put their posture in the correct position during all daily activities [27] (Table 3).



Data analysis
To check the normality of the data distribution, the Shapiro-Wilk test was used. The significance level of upper limb function and neck proprioception was 0.05, indicating the normal data distribution. Due to the nature of this study, the analysis of covariance (ANCOVA) was used to examine the intra-group differences of the subjects and also to examine the effect of training on the dependent variable, the paired t-test was used.

Results
Personal characteristics of the subjects of the two experimental and control groups are presented in Table 4.



The result of the independent t-test in the pre-test did not show a significant difference, which indicated the homogeneity of the subjects in personal characteristics. The paired t-test results showed that in the experimental group, unlike the control group, there was a significant difference between the pre-test and post-test variables in the performance of the upper extremity and proprioceptive in the neck region (Table 5).



The mean pre-test values of the two control and experimental groups were analyzed using an independent t-test, and considering no significant difference in the pre-test, ANCOVA was used to eliminate the minimal effects of the test. In other words, the significant level of upper extremity function and proprioception in the neck region was more significant than 0.05. The equality of variances was checked through Levine’s test. The F value obtained for the upper extremity function variable was 4.094 with a P=0.089. On the other hand, for the sense of joint position in flexion, the F=2.969, P=0.101, for extension, the F=2.541,P=0.112 for left rotation, the F=4.740, P=0.079 and finally, for right rotation the obtained F=1.031, P=0.319. Therefore, the hypothesis of homogeneity of variances among the groups was confirmed. The results of ANCOVA to evaluate the effectiveness of the intervention in the performance score of the upper extremity and proprioception of the neck area are presented in Tables 6 and 7. There was a significant difference between the control and intervention groups in both function and proprioceptive of the neck area after the intervention (P≤0.05). 






Discussion
The findings of the current research showed that the upper extremity function of studied samples in the intervention group improved after the specified period of time in the pre-test and post-test and this improvement was significant according to the post-test score. No study was found in this field. For this reason, the studies similar to the present study were examined. 
Özdemir Görgü et al. reported that Schroth’s functional exercises are effective in improving spine abnormalities, such as hyperkyphosis. They also affect the quality of life and balance of the elderly [28]. The similarity of the two research on the correction of kyphosis anomaly and its effect on balance can be mentioned. The present research was on depressed people with upper crossed syndrome. Kim et al. investigated the effect of shoulder stability exercises and pectoralis minor muscle stretching on the function and strength of shoulder muscles in healthy young people with rounded shoulder posture and reported a significant improvement in the performance of the subjects [29]. In addition, the present research was in line with the results of the research of Jang et al. (2019) [30]. They examined the effect of stability exercises on balance in older women with kyphosis posture and reported the effectiveness of these exercises. Both studies were similar in terms of placing the deformity kyphosis posture and correcting the deformity [30]. 
Sun et al. also investigated the effect of corrective exercises on posture, balance, and health of older women. The findings of this study showed that a properly designed exercise program could be useful in improving spine posture, balance, and health in older women with kyphosis anomalies [31]. On the other hand, Katzman et al. after implementing a 12-week training program twice a week, reported a 5±3° decrease in the kyphosis angle for women with hyperkyphosis above 50° [25]. There was no significant improvement in the balance and stability of these people. Probably, the reason for the inconsistency between the results of Katzman et al. and our results is the low number of training sessions during the week (two sessions during the week), because at least three training sessions should be done during the week to create the necessary muscle adaptations. 
It is concluded that the corrective exercises of the present study, due to strengthening the proprioception of the neck and shoulders, through simultaneous contraction of agonist and antagonist muscles, in addition to the treatment of upper crossed syndrome, might have increased the flexibility of the upper quadrant muscle fibers of the body. This factor can justify the comprehensive corrective exercises used in this research to improve the length-tension relationship in improving performance. From another point of view, in the current corrective exercises, because chin-ups were performed at the same time, and at the same time, scapular retraction exercises were performed with the use of a theraband, this procedure led to an increase in the strengthening and better recall of the small and deep muscles of the neck area and instead of leading to backward movement, they led to backward rotation. This led to the improvement of the length of the lever arm and the strengthening of the intra-articular muscles of the neck, and on the other hand, it led to an increase in the flexibility of the shortened muscles (upper extensors of the neck area). The presence of scapular retraction exercise at the same time as the previous exercise leads to the strengthening of scapular adductor muscles. This causes the mechanical receptors in the cervical and back spine to be stimulated and leads to an improvement in the sense of joint position in the neck area [24]. Also, due to long-term exposure to people with depression, they were advised to have a correct posture during daily activities. Therefore, it is possible that correcting muscle imbalance and reducing the number of upper extremity abnormalities, such as forward head and kyphosis, which are caused by a long posture or repetitive movements on the sagittal (anterior-posterior) surface, improve performance in our subjects [18]. It seems that in addition to corrective exercises, the role of games is also very important in improving performance. According to the researchers of this study, the review and design of each of the games were based on the purpose of the research. For example, in the catapult game, the patient moves his/her shoulders back to catch the ball and must maintain this position, which requires the contraction of the external rotator muscles of the scapula, as well as the lower part of the trapezius muscles and increasing rhomboid muscle recruitment. When these muscles are in a state of contraction, they lead to the improvement of the scapula and increase the stability of the scapula. Another game played in this study was passing under the bridge. In this game, at the same time as playing the bridge, the patient put his/her external rotator muscles and pectoral muscles in a stretched position. On the other hand, one of the prominent features of this game is that while playing it, the shoulder blades are brought together and the vertebrae are stretched and opened. Therefore, performing this exercise puts the alignment of the body in the correct position. All these explanations can be one of the factors to improve one’s performance. It seems that this has effectively improved the function of the upper limbs of people suffering from depression.
Other results showed a significant improvement in the range of motion and joint position sense in the neck region due to corrective exercises. The joint position sense in the neck region refers to the interface between the neck and the musculoskeletal system [32]. Afferent information is provided through data from visual, vestibular, and proprioceptive systems. Muscle spindles detect the stretching of agonist muscles and transmit sensory information to the spinal cord through afferent fibers. This data is then relayed to alpha and gamma motor nerves, which, in turn, provide feedback to muscle fibers and muscle spindles, respectively. This process results in muscle contractions that help control excessive postural sway [32]. Clinically, maintaining a stable posture in the body requires coordinated activity and processing of afferent information from all three sensory systems. The cervical spine, in particular, plays a crucial role in proprioception and upper extremity function, with a high density of muscle spindles found in the deeper neck muscles contributing to improved proprioception [33]. A high density of the muscle spindles in the minor deep muscles of the neck plays a crucial role in improving proprioception and upper extremity function (Murphy, 2000). In cases of upper crossed syndrome, functional disorders can arise in the muscle and joint receptors in the neck area, potentially leading to heightened sensitivity of muscle spindles and increased stimulation of gamma motor neurons. This can have a detrimental impact on proprioception and movement control [34]. Although there have been studies in this field, it is worth noting that their study populations differ from the population of this study. Also, no study was found that specifically focused on the simultaneous impact of corrective exercises, corrective games, and postural correction training on cervical proprioception in individuals suffering from depression. Some studies with certain variables aligned with this research are those by Choi et al. [35], Battal et al. [36], and Lee et al. [37]. Battal et al. reported that upper thoracic region exercises improve cervical proprioception in people with forward head posture. They believed that this was due to an increase in the activity of the Golgi apparatus and muscle spindles [36]. Choi et al. showed that functional exercises as well as the use of kinesio tape improved joint position sense in the neck region in adults with forward head deformity. In their results’ justification section, they noted that the improvement in joint position sense in the neck region is linked to reduced pain levels and decreased postural deviations [35]. Also, Kim et al. 2006 investigated the effect of proprioceptive exercises on neck posture reconstruction error in people with chronic neck pain. They reported that proprioceptive training in these people reduces the reconstruction error and the intensity of pain. Regulating the general body posture and movement control depends on a continuous flow of peripheral information, and proprioception is an important part of this information. Proprioception plays a crucial role as it serves as a protective mechanism against movement-related injuries, helps maintain joint stability, and acts as a natural coordinator during physical activities. When proprioception in the joints is compromised, it can disrupt the reflex pathways responsible for stabilizing muscles. This makes the improvement of proprioception particularly significant for individuals with depression. Studies have shown that proprioception is trainable, and rehabilitation programs that emphasize proprioception training have been shown to enhance functional movements [38]. Several studies have emphasized the importance of precise muscle spindle feedback for accurate movements. In individuals with upper crossed syndrome, abnormal stress on the joints can interfere with afferent feedback from muscle spindles and disrupt proprioceptive function [39]. In this context, selected corrective exercises can improve proprioception through several possible mechanisms. These exercises appear to engage the deep flexor muscles of the neck, which are rich in muscle spindles while reducing the activity of superficial flexor neck muscles. The exercises in this study may activate message transmission pathways, increase synaptic connections, and enhance the activity of the Golgi apparatus and the muscle spindles [40].

Conclusion
Eight weeks of the selected corrective program leads to the improvement of upper extremity function and neck proprioception in people suffering from depression with upper crossed syndrome. As a result, the corrective and functional exercises can be used as a comprehensive treatment protocol in improving the disorders related to neck proprioception and increasing upper extremity function in people suffering from depression.

Ethical Considerations

Compliance with ethical guidelines
This research approved by the Ethical Committee of  Sport Sciences Research Institute (Code: R1SSRI.REC-2106-1042).

Funding
This article was extracted from the PhD dissertation of Taleb Fadaei Dehcheshmeh, approved by University of Guilan.

Authors' contributions
Conceptualization, investigation, methodology and visualization: Taleb Fadaei Dehcheshmeh; Data curation: Taleb Fadaei Dehcheshmeh and Ali Shamsi Majelan; Writing: Ali Shamsi Majelan and Hassan Daneshmandi; Formal analysis and final approval: All authors. 

Conflict of interest
The author declared no conflict of interest.

Acknowledgments
The authors would like to thank the subjects and all the people who somehow contributed to the completion of this study.





References