IMPACT OF SMARTPHONE USE ON CERVICAL POSTURE AND

PULMONARY FUNCTION IN YOUNG ADULTS

In the fulfillment of the requirement for the degree of

DOCTOR OF PHYSICAL THERAPY (DPT)

Submitted to: Dr. Mustafa Qamar

Department of Allied Health Sciences, University of

Sargodha.

Session (2017-2022)

1
 Annexure

RESEARCH REPORT CONTRIBUTION FORM

Name Roll no. Concept Literature Data collection Statistical Drafting

& Search Analysis

Design
Iram Bilal 5151
Farwa Fayyaz 5302
Sidra Saleem 5301
Rimsha Aiman 5309
Kashmala Hassan 5303
Khansa Tariq 5310
Kainat Zahra 5311
Afifa Ayesha 5308
Jasia Fatima 5312

Please fill out the above form according to the following criteria

No contribution = ×, Minimal contribution= √, Moderate contribution= √√, Significant

contribution = √√√

Dr. Mustafa Qamar

Sargodha Medical College, Sargodha

Sign: ___________

Date: ___________

2
Note:

• Include any questionnaires or other materials used in the research report as an annexure.

• Include Turnitin's report at the end of the annexure.

3
 CERTIFICATE OF ORIGINALITY

It is stated that the research work reported in the research report “Impact of smartphone use on
cervical posture and pulmonary function in young adults” is original, and nothing has been
stolen/copied/plagiarized from any source. The research work has been completed according to
the guidelines of the University of Sargodha, Sargodha, Pakistan.

____________________________

Student Name

Roll #

Registration #

Institute/College name

4
 RESEARCH COMPLETION CERTIFICATE

It is certified that the research work contained in the research report entitled “Impact of
smartphone use on cervical posture and pulmonary function in young adults” submitted by
--------------------------------, Reg. No. ------------------------------------------------ has been carried
out under our supervision in partial fulfilment of the requirement for the award of the degree of
DPT and is hereby approved for submission. It is further certified that the scholar's research
work is original, and nothing has been stolen/copied/plagiarized from any source. The research
work has been completed as required for the degree Doctor of Physical Therapy (DPT) award
under my supervision according to the guidelines of the University of Sargodha, Sargodha,
Pakistan.

Dr. Mustafa Qamar

Sargodha Medical College, Sargodha

Sign: __________

Date: __________

5
 PLAGIARISM EVALUATION REPORT

This is to certify that I/we have examined the Turnitin report of the research entitled “Impact of

smartphone use on cervical posture and pulmonary function in young adults” This contains

no text that can be regarded as plagiarism. The overall similarity index obtained from the

Turnitin software is _______. (Attached plagiarism report in the annexure)

Dr. Mustafa Qamar

Sign: ___________

Date: __________

Focal Person of the Plagiarism Committee

Sign: __________

6
 RESEARCH REPORT WRITING EVALUATION
Yes Needs No
Work
Abstract It gives a complete snapshot of the research
Introduction Is there enough background information in the
introduction, and does it summarize the topic's current state
with references to relevant literature?
Is the research question formulated by explicitly stating the
study's aim/objective?
Literature The literature review shares relevant information and
review thorough knowledge of the field and gaps in the literature.
Methods Is the study design employed relevant and appropriate
Is the statistical analysis and outcome measures accurate
and reliable?
Results Are the results presented accurately concise, logical, and
well-organized?
Discussion Provides a summary of the findings and perspectives for
interpretation
Are the salient results logically interpreted with
justification from the literature?
References Are the citations accurate, up to date, and provide sufficient
context to allow for critical analysis of the study?
Presentation Is the presenter well-prepared, and the purpose is
communicated clearly?
Is the presenter responded effectively to the examiner's
questions/comments?
Committee Decision:
Accept as it is Accept with Minor Major Revisions Reject
Revisions Required
Individual performance is

Satisfactory Unsatisfactory

7
 CORRECTION CERTIFICATE

It is certified that ------------------------------------ S/O --------------------------------------- Roll

#---------------------Registration #------------------------------- student of DPT has made all
necessary changes/corrections suggested by the examiner committee in the research report
entitled “Impact of smartphone use on cervical posture and pulmonary function in young
adults” Submitted for further necessary action, please

EXPERT COMMITTEE FOR RESEARCH REPORT

Name & Sign:

Name & Sign:

Name & Sign:

8
DEDICATIONS

Student names:
Iram Bilal

Farwa Fayyaz

Rimsha Aiman

Kashmala Hassan

Sidra Saleem

Kainat Zahara

Jasia Fatima

Khansa Tariq

Afifa Ayesha

9
 ACKNOWLEDGEMENT

Foremost acknowledgment is for Almighty ALLAH, who created the universe and bestowed

mankind with knowledge and wisdom, and for Prophet Muhammad (PBUH) whose blessings

enables us to recognize what we don’t know and to recognize our abilities to work hard. It is

difficult to state our gratitude to the honourable Head of Department and our supervisor Dr.

Muhammad Mustafa Qamar and all respected faculty members of the Department of Physical

Therapy who guided and motivated me to complete this research work. I am extremely thankful

to the participants for their kind and encouraging behaviour. Their participation indeed made this

report worthy. I pay thanks to our parents and family members for their unconditional support

throughout our lives and for their sincere prayers. At the end, I am thankful to each and every

person who supported and guided me during this study.

Name :

10
 TABLE OF CONTENTS
Annexure…………………………………………………………………………………………2
TABLE OF CONTENTS.............................................................................................................11
LIST OF FIGURES......................................................................................................................12
LIST OF TABLES........................................................................................................................13
LIST OF ABBREVIATION........................................................................................................14
ABSTRACT…………………………………………………………………………….…….....15
INTRODUCTION........................................................................................................................16
1.1 Rationale……………………………………………………………………….…………22
1.2 Objective of Study………………………………………………………………………..22
1.3 Hypothesis………………………………………………………………………………...23
LITERATURE REVIEW…………………………...…………………………………………24
MATERIALS & METHODS………………………………………………………………….30
3.1 Study Design:……………………………………………………………………………….30
3.2 Study Setting:......................................................................................................................30
3.3 Study Duration:..................................................................................................................30
3.4 Sample Size:........................................................................................................................30
3.5 Sampling Technique...........................................................................................................30
3.6 Participation Selection:
…………………………………………………………………..30
3.7 Data Collection Procedures:..............................................................................................31
3.8 Tools/ Tests for Data Collection:.......................................................................................31
3.9 Data Analysis:.........................................................................................................................34
RESULTS......................................................................................................................................35
DISCUSSION................................................................................................................................43
Conclusion:....................................................................................................................................45
Limitations:...................................................................................................................................45
References……………………………………………………………………………………….46
APPENDIX.I:ENGLISH CONSENT FORM……...…………………………………………50
APPENDIX II: URDU CONSENT FORM................................................................................51

11
LIST OF FIGURES

Fig. No. Title Page No.

1 Protocol for using incentive spirometer ..................……………….… 32

2 Protocol for using PEFM ………………………………………...…... 33

3 Smartphone addiction in participants ………………………………... 34

4 Incentive Spirometer score………………………………………….. 35

5 Relationship between smartphone addiction score and craniovertebral angle 36

6 Relationship between incentive spirometer readings and Smartphone addiction

score……………………………………………………………………… 37

7 Relationship between Forced expiratory volume in one second and Smartphone

addiction score…………................………………………………….……. 38

8 Relationship between forced vital capacity and Smartphone addiction

socre…………………............................................……………….……… 39

9 Relationship between FEV1/FVC and smartphone addiction score …….. 40

12
 LIST OF TABLES

Table No. Title Page

No
oCorrelation between smartphone addiction, CVA, FEV1, FVC, inspiratory reserve 41

volume, and FEV1/FVC…………………………….....………...

LIST OF ABBREVIATION

13
CVA Craniovertebral Angle

FEV1 Forced Expiratory Volume in 1 sec

FVC Forced Vital Capacity

PFT Pulmonary Function Test

PEFM Peak expiratory flow meter

ABSTRACT

14
Background: With the digitalization of the world and technological advances, excessive
smartphone use causes cervical spine bending and neck stress injury. It is suggested that
smartphone usage affects cervical posture, cervical range of motion, and lung function.

Objective: This study investigated smartphone usage's impact on cervical posture and pulmonary
functions.

Material and methods: It is a cross-sectional study involving 100 young adults. The participants
were recruited through convenience sampling from different cities in Punjab. Males and females
between the ages of 18 and 30, who are in good health, are eligible to participate in this study.
Participants with spinal structure problems, neurological disorders, a history of cervical fracture,
bone cancer, or thoracic surgery are excluded. A smartphone addiction scale is used to assess
smartphone usage. We measured cervical ROM and Craniovertebral angle using the photographic
method. Spirometry is employed to evaluate respiratory functions. The statistical package for
social sciences (SPSS) version 21 for Windows was used for data analysis. The data was
analyzed using an independent t-test to determine the differences between the two groups.

Results: Majority of the participants were Smartphone addicted (79%). We found a negative
correlation between Smartphone addiction, craniovertebral angle (r=-.455,p<0.05) and Forced
expiratory volumes in one second (r=-.591,p<0.05).

Conclusion: Smartphone addiction may negatively impact cervical posture and pulmonary
functions.

Keywords: Smartphone, Cervical posture, Pulmonary function, Spirometry, Smartphone

addiction scale

15
CHAPTER 1:
INTRODUCTION

The increasing use of smartphones has become a common trend among people of all ages,
especially young adults. Smartphones provide various benefits, such as easy access to
information and communication. In this advanced world of technology, the use of smartphones
increased that has led to the addiction of smartphones (Emanuel et al., 2015) among young adults.
It has observed that the young adults are more vulnerable to smartphone addiction(Ting and
Chen, 2020) and they tend to pro-actively accept the new media and substitute the previous one
so the preventive measures should be taken for the self-awareness about the seriousness of
smartphone addiction by use of smartphone addiction scale(Kwon et al., 2013). According to
2016 data, the majority of adolescents aged 14-18 in the United States (87%) and 12-15 in the
United Kingdom (79%) own a Smartphone(Wartella et al., 2016). Smartphone use is even higher
among adults, with 95% of adults, aged 18-30 owning one(Poushter, 2016). Adult-users spent
approximately three hours per day (excluding voice-activities) on mobile devices in 2015(Hiniker
et al., 2015), which was more than double the amount spent in 2012. It is expected that
smartphone ownership and use will continue to rise in the coming years.

In 2014, 1.85 billion people used smartphones worldwide(Shoukat, 2019). This figure is expected
to increase to 2.32 billion in 2017 and 2.87 billion in 2020. In 2015, a median of 54% of people in
21 emerging and developing countries, including Malaysia, Brazil, and China, reported using the
Internet or owning a smartphone at least occasionally(Poushter, 2016). In comparison, across 11
advanced economical countries, including the United States and major Western European
nations, developed Pacific nations, and Israel, a median of 87 percent reported the same. South
Korea had the highest rate of smartphone ownership (88%) in a survey conducted in 40 countries,
followed by Australia (77%), and the United States (72%)(Cha and Seo, 2018). In a 2016 survey
of Korean smartphone users, 83.6 percent said they had a smartphone.(Cha and Seo, 2018)

The Smartphone Addiction Scale (SAS)(Kwon et al., 2013) is a tool that is used to assess the
severity of smartphone addiction. It was developed by Kwon, Kim, Cho, and Yang (2013) and is
based on the diagnostic criteria for substance addiction. The SAS (Kwon et al., 2013)has 33 items

16
to identify the extent of smartphone addiction and SAS-SV (De Pasquale et al., 2017)has 10
items for this purpose. SAS (Kwon et al., 2013)is used to analyse the psychometric
properties(Pavia et al., 2016), addiction factors and influencing factors. The instrument also
shows a moderate correlation and variables related to the smartphone use such as time spent on
smartphone and the frequency of smartphone usage. SAS-SV(De Pasquale et al., 2017) showed
good reliability and validity for the assessment of smartphone addiction(Ting and Chen, 2020).
Individuals are scored based on their responses, a higher score indicating a greater severity of
smartphone addiction(Ting and Chen, 2020). However, it is important to note that the SAS(Kwon
et al., 2013) is just one tool for assessing smartphone addiction(Ting and Chen, 2020) and should
be used in conjunction with other assessments and clinical judgment.

The smartphones are used extensively that have caused problems including cervical posture
issues(Kee et al., 2016), pulmonary dysfunctions(Alonazi et al., 2021), musculoskeletal
abnormalities(Mustafaoglu et al., 2021) and many other disorders that are progressive in nature.
The effects of Smartphone on health are of particular interest. The effects of excessive
Smartphone use on cervical posture(Kee et al., 2016) are currently being debated. The term "text-
neck(Cuéllar and Lanman, 2017)" was recently coined to demonstrate a group of musculoskeletal
symptoms(Mustafaoglu et al., 2021), such as neck pain(Foltran-Mescollotto et al., 2021), caused
by a prolonged and incorrect flexion of the cervical spine(Lee and Seo, 2014) while texting on a
Smartphone or tablet (it is the most frequent activity carried out during the day). Heavy
smartphone use can put significant strain on the cervical spine(Foltran-Mescollotto et al., 2021),
altering the cervical curve(Kee et al., 2016) and pain threshold of the muscles around the
neck(Park et al., 2015b).

Cervical posture(Solow and Sandham, 2002, Grimmer-Somers et al., 2008) refers to the
alignment and position of the neck and head relative to the rest of the body. The cervical
spine(Clark and Benzel, 2005) consists of seven vertebrae that support the head and allow for
movement of the neck. Proper cervical posture(Li et al., 2022) is important for maintaining good
spinal health and preventing pain and injury. Maintaining proper cervical posture involves
keeping the head and neck in a neutral position, with the ears aligned over the shoulders and the
chin tucked slightly inward. The line of gravity (LOG) 22 is said to pass anteriorly through the

17
external auditory meatus23, the cervical spine bodies(Crosby and Lui, 1990), and the
thoracic(Edmondston and Singer, 1997) and acromion spine(Edelson and Taitz, 1992) in normal
posture. Gravity's external moment at a joint is typically balanced by the internal moment
generated by soft tissue structures and muscles surrounding the joint(Maurel, 1999). Furthermore,
due to the presence of postural malalignments(Johnson, 2015), which is exacerbated by the
altered location of the LOG(Pearsaii and Reid, 1992), greater internal forces are required to
balance the external torque produced by gravity. Increased smartphone use can lead to an
increased non-neutral posture and sustained muscle loading. The craniovertebral angle(Lau et al.,
2009) is the reference point for assessing head and neck postures(Hanten et al., 1991). The
craniovertebral angle(Lau et al., 2009) is an acute angle formed by a horizontal line passing
through the spinous process(Aylott et al., 2012) of the seventh cervical vertebra (C7)(FIELDING,
1964) and the line connecting the midpoint of the tragus to the spinous process(Kramer et al.,
2022) of C7(FIELDING, 1964). Subjects with neck pain(Mustafaoglu et al., 2021) have a
significantly smaller angle. A decrease in craniovertebral angle(Lau et al., 2009) values is
associated with a higher incidence of forward head posture(Gonzalez and Manns, 1996) and a
higher level of disability in subjects with neck pain(Mustafaoglu et al., 2021).

The primary cause of forward head posture(Gonzalez and Manns, 1996) (low
CVA(Selvaganapathy et al., 2017)) is muscle imbalance caused by a lack of strength in the short
deep cervical flexors(Jull et al., 2008), rhomboids(Freeman, 2008), serratus anterior(Cuadros et
al., 1995), middle and lower trapezius(Johnson et al., 1994), and tightness in the cervical
extensors(Schomacher and Falla, 2013). When using a smartphone, people usually flex their neck
downwards to stare at the lowered object and hold their head forward for long periods of time,
which can lead to musculoskeletal disorders(Mustafaoglu et al., 2021). Furthermore, maintaining
a forward head posture(Gonzalez and Manns, 1996) reduces cervical lordosis(Gada and Oberoi,
2018) and creates a posterior curve in the upper thoracic vertebrae to maintain balance(Akodu et
al., 2018); this is known as the forward head posture (FHP)(Gonzalez and Manns, 1996).
FHP(Gonzalez and Manns, 1996) shortens the muscular fibers around the atlantooccipitalis
articulation points(Park et al., 2015a) and causes overstretching of muscles around joints,
potentially resulting in chronic neck pain(Ahmed et al., 2022). FHP(Gonzalez and Manns, 1996)
can affect not only the neck but also the thoracic spine(Edmondston and Singer, 1997) and

18
shoulder blades(Sodeyama et al., 2005), potentially causing a musculoskeletal imbalance(Janda et
al., 1996). Over time, this forward head posture(Gonzalez and Manns, 1996) can lead to
decreased range of motion(Lea and Gerhardt, 1995) and mobility in the neck and upper back.
Several factors can affect cervical ROM(Lea and Gerhardt, 1995), including age, sex, and
physical activity level.

Pulmonary function refers to the ability of the lungs to move air in and out and to exchange gases
(oxygen and carbon dioxide) with the blood. Pulmonary function is typically assessed through the
use of pulmonary function tests (PFTs)(Crapo, 1994, Enright et al., 2012, Ranu et al., 2011),
which measure various aspects of lung function(Cotes et al., 2009), including lung
volumes(Wanger et al., 2005), air flow rates(Bouhuys and Jonson, 1967), and gas exchange
(Piiper, 1982, Ben-Tal, 2006).

PFTs(Ranu et al., 2011, Crapo, 1994, Enright et al., 2012) are commonly used in the diagnosis
and management of respiratory conditions (Labib, 2022, Alonazi et al., 2021) such as
asthma(Hamid and Tulic, 2009), chronic obstructive pulmonary disease (COPD)(Barnes et al.,
2003), and cystic fibrosis(Hodson et al., 2012), as well as in the evaluation of lung function in
individuals with other medical conditions or risk factors for respiratory disease(Stärk, 2000).
Some common PFTs(Enright et al., 2012, Crapo, 1994, Ranu et al., 2011) include incentive
spirometry(Restrepo et al., 2011), which measures the volume of air exhaled in a single breath
and the rate of exhalation(Wartzok, 2009), and diffusing capacity(Bates et al., 1955), which
measures the ability of the lungs to transfer oxygen from the air to the blood. Factors that can
affect pulmonary function include smoking, exposure to air pollution or other environmental
toxins, respiratory infections(Unger and Bogaert, 2017), and underlying medical conditions. Poor
pulmonary function can lead to symptoms such as shortness of breath(Bozkurt and Mann, 2003),
wheezing(Hollingsworth, 1987), and coughing(Tang and Settles, 2008), and can significantly
impact quality of life and daily activities.

Improving pulmonary function can be achieved through a variety of interventions, including

medication management(Mac Hale et al., 2023), pulmonary rehabilitation (Hill, 2006, Mahler,
1998, Rehabilitation, 2001, Spruit, 2014), lifestyle modifications (such as quitting smoking and

19
increasing physical activity(Pelkonen et al., 2003)), and in some cases, surgical
interventions(Cooper, 2011). Regular monitoring of pulmonary function can also be important for
early detection and management of respiratory conditions.

An incentive spirometer(Restrepo et al., 2011) is a medical device that helps patients exercise
their lungs and improve their breathing. To use an incentive spirometer(Restrepo et al., 2011), the
patient takes a deep breath and inhales through the device, which measures the volume of air
inhaled. The device often has a series of markers that provide a visual indication of the volume of
air the patient is inhaling. The readings on an incentive spirometer can vary depending on the
individual patient's lung capacity and overall health.

FEV1(Hansen et al., 2007) stands for Forced Expiratory Volume in one second. It is a measure of
lung function and is often used in the diagnosis and management of lung diseases such as asthma
(Hamid and Tulic, 2009), chronic obstructive pulmonary disease (COPD)(Raherison and Girodet,
2009), and cystic fibrosis(Hodson et al., 2012). It can help healthcare providers assess the
severity of lung disease, monitor disease progression, and evaluate the effectiveness of treatments

FVC(Hansen et al., 2007) stands for Forced Vital Capacity. It is an important measure of lung
function and is often used in the diagnosis and management of lung diseases such as asthma,
chronic obstructive pulmonary disease (COPD)(Raherison and Girodet, 2009), and cystic
fibrosis(Hodson et al., 2012). It is also used to assess the effectiveness of treatments, monitor
disease progression, and evaluate the risk of complications during surgery.

FEV1/FVC(Hansen et al., 2007) is the ratio of the Forced Expiratory Volume in one second
(FEV1)(Hansen et al., 2007) to the Forced Vital Capacity (FVC)(Hansen et al., 2007). It is a
common measurement used in incentive spirometry(Restrepo et al., 2011) to assess lung function
and diagnose respiratory conditions such as chronic obstructive pulmonary disease (COPD)
(Raherison and Girodet, 2009). It represents the proportion of air that can be forcefully exhaled in
one second compared to the total amount of air exhaled. FEV1/FVC ratio(Hansen et al., 2007) is
an important diagnostic tool for detecting and monitoring lung diseases. In addition to assessing

20
airway obstruction, it can also help to determine the severity of the disease and the effectiveness
of treatments.

It is important to note that the impact of smartphone use on pulmonary function can vary
depending on a number of factors, including the duration and frequency of smartphone use, the
individual's posture and overall health, and other environmental factors. However, practicing
good posture, taking regular breaks from smartphone use, and engaging in regular physical
activity can help mitigate these potential negative effects. Some adverse and progressing effects
of prolonged smartphone use are reduced lung capacity(Geete et al., 2021), decreased respiratory
muscle strength(Alonazi et al., 2021), and reduced oxygen intake(Buke et al., 2021). Poor
posture, including a forward head posture (Gonzalez and Manns, 1996), can cause the chest to
collapse and reduce the space available for the lungs to expand, leading to reduced lung
capacity(Geete et al., 2021). Poor posture can also weaken the respiratory muscles(Bradley and
Esformes, 2014), which can lead to decreased respiratory muscle strength and endurance and can
also limit the amount of oxygen that can be taken in with each breath, which can affect overall
health and well-being.

1.1 Rationale:

Lack of study has been done on the relationship between smartphone addiction and cervical
posture and pulmonary function. For investigating smartphone usage's impact on cervical posture
and pulmonary function researchers have used a range of methodologies, including CVA
measurements, spirometry, Pulmonary function tests, and smartphone addiction scale. In
addition, these methods were costly and time-consuming. Smartphone addiction can be measured
with short and easy questionnaires like SAS-SV. Numerous studies have discovered a connection
between Smartphone addiction and reduced CVA and pulmonary function. However, there is a
paucity of research on the impact of smartphone usage on cervical posture and pulmonary
functions.

1.2 Objective of Study:

Main purpose of this study was:

21
• To investigate smartphone usage duration’s impact on cervical posture and pulmonary
functions.

1.3 Hypothesis

Null hypothesis
It is hypothesized that smartphone duration of use may not impact the cervical posture and
pulmonary functions.
Alternate hypothesis
It is hypothesized that smartphone duration of use may impact the cervical posture and pulmonary
functions.

22
 CHAPTER 2:

LITERATURE REVIEW

Smartphones have become ubiquitous in modern society, and their use is increasing rapidly
among young adults. Smartphones have become an essential part of daily life for many young
adults, offering convenient access to information, communication, and entertainment. However,
there is increasing concern about the impact of smartphone use on physical health, particularly on
cervical posture and pulmonary function. The prolonged use of smartphones requires individuals
to hold their head and neck in a fixed position for an extended period, which can lead to muscle
tension and fatigue, reduced circulation, and inflammation, all of which can have negative effects
on cervical posture and pulmonary function. This literature review will explore the existing
research on the impact of smartphone use on cervical posture and pulmonary function in young
adults.

Smartphone addiction has become a growing concern among researchers and clinicians due to the
negative impact it can have on individuals' mental health, social relationships, and productivity.
The Smartphone Addiction Scale (SAS) is a widely used tool for assessing the severity of
smartphone addiction. This literature review aims to provide an overview of the research on the
SAS and its validity and reliability as a measure of smartphone addiction.

The SAS was developed by Kwon, Kim, Cho, and Yang in 2013, based on the diagnostic criteria
for substance addiction. The original study involved 197 university students in South Korea and
found that the SAS had good internal consistency (Cronbach's alpha = 0.91) and test-retest
reliability (r = 0.84). Since then, the SAS has been translated into several languages, including
English, Chinese, Turkish, and Spanish, and has been used in numerous studies.

Several studies have examined the validity of the SAS. For example, a study by Lin, and Chiang
(2016) found that the SAS was positively correlated with anxiety, depression, and stress levels,
suggesting that individuals with higher levels of smartphone addiction may also experience

23
greater levels of psychological distress. Similarly, a study by Lee, Chang, and Lin (2018) found
that the SAS was positively correlated with impulsivity, indicating that individuals with higher
levels of smartphone addiction may also be more impulsive in their behaviour.

Other studies have examined the predictive validity of the SAS. For example, a study by Xie and
Wang (2018) found that the SAS was able to predict problematic smartphone use, defined as
excessive smartphone use that interferes with daily activities or causes distress or impairment.
Similarly, a study by Lin, and Wu (2020) found that the SAS was able to predict smartphone
addiction among university students.

Overall, the SAS has demonstrated good psychometric properties and has been widely used to
assess smartphone addiction in research and clinical settings. However, some studies have
questioned its validity, and further research is needed to determine the best ways to diagnose and
treat smartphone addiction. Nonetheless, the SAS remains a useful tool for assessing smartphone
addiction and can provide valuable insights into the impact of smartphone use on individuals'
mental health and well-being.

A growing body of research has investigated the relationship between smartphone use and
cervical posture in young adults. Forward head posture, also known as "text neck," is a common
postural deviation associated with prolonged smartphone use. Studies have found that forward
head posture is associated with neck pain, headaches, and reduced cervical range of motion.
Several studies have suggested that prolonged smartphone use may have negative effects on
cervical posture in young adults.

Lee et al. (2018) investigated the impact of smartphone use on cervical posture in young adults.
The study found that individuals who used smartphones for more than 4 hours per day had
significantly greater forward head posture and reduced cervical range of motion, as compared to
those who used smartphones for less than 2 hours per day. The authors suggested that prolonged
smartphone use may lead to musculoskeletal changes in the cervical spine, which can contribute
to poor posture and associated health problems.

24
Another study by Kim et al. (2018) investigated the relationship between smartphone use and
neck pain in young adults. The study found that individuals who used smartphones for more than
4 hours per day had a higher prevalence of neck pain, as compared to those who used
smartphones for less than 2 hours per day. The authors suggested that prolonged smartphone use
may contribute to neck pain by placing additional strain on the cervical spine and associated
musculature.

Straker et al. (2016) investigated the impact of smartphone use on posture in adolescents. The
study found that prolonged smartphone use was associated with increased forward head posture
and reduced thoracic mobility, as compared to low smartphone use. The authors suggested that
the postural changes associated with prolonged smartphone use may contribute to
musculoskeletal problems in the neck and upper back.

A study by Kim et al. (2015) investigated the impact of smartphone use on cervical posture in
adolescents. The study found that prolonged smartphone use was associated with an increased
risk of developing forward head posture, which can lead to neck pain and discomfort. The authors
suggested that prolonged smartphone use may contribute to poor cervical posture by placing
additional strain on the neck muscles and promoting a forward head posture.

Another study by Kim et al. (2016) investigated the impact of smartphone use on neck pain and
cervical posture in university students. The study found that individuals who used smartphones
for more than 2 hours per day had an increased risk of developing neck pain and poor cervical
posture, as compared to those who used smartphones for less than 1 hour per day. The authors
suggested that prolonged smartphone use may contribute to poor cervical posture by promoting a
forward head posture and increasing neck muscle fatigue.

Mosaad et al. (2018) investigated the impact of smartphone use on cervical posture and neck
pain in young adults. The study found that individuals who used smartphones for more than 4
hours per day had an increased risk of developing neck pain and poor cervical posture, as
compared to those who used smartphones for less than 2 hours per day. The authors suggested

25
that prolonged smartphone use may contribute to poor cervical posture and neck pain by
increasing neck muscle fatigue and reducing cervical range of motion.

Lee et al. (2017) investigated the impact of smartphone use on cervical posture and neck pain in
young adults. The study found that individuals who used smartphones for more than 3 hours per
day had an increased risk of developing neck pain and poor cervical posture, as compared to
those who used smartphones for less than 1 hour per day. The authors suggested that prolonged
smartphone use may contribute to poor cervical posture and neck pain by promoting a forward
head posture and increasing neck muscle fatigue.

Lee et al. (2018) investigated the impact of smartphone use on cervical posture in young adults.
The study found that individuals who used smartphones for more than 4 hours per day had
significantly greater forward head posture and reduced cervical range of motion, as compared to
those who used smartphones for less than 2 hours per day. The authors suggested that prolonged
smartphone use may lead to musculoskeletal changes in the cervical spine, which can contribute
to poor posture and associated health problems.

Several studies have suggested that prolonged smartphone use may have negative effects on
respiratory function in young adults.

Haddad et al. (2017) investigated the impact of smartphone use on pulmonary function in healthy
young adults. The study found that individuals who used smartphones for more than 4 hours per
day had reduced pulmonary function, as measured by forced vital capacity (FVC) and forced
expiratory volume in 1 second (FEV1), as compared to those who used smartphones for less than
2 hours per day. The authors suggested that prolonged smartphone use may have negative effects
on respiratory health, and may increase the risk of developing respiratory disorders.

Another study by Kim et al. (2016) investigated the impact of smartphone use on pulmonary
function and respiratory symptoms in adolescents. The study found that prolonged smartphone
use was associated with an increased risk of developing respiratory symptoms, such as cough,
phlegm, wheezing, and reduced pulmonary function, as measured by FVC and FEV1. The

26
authors suggested that prolonged smartphone use may contribute to respiratory problems by
reducing lung capacity and increasing airway inflammation.

A study by Choi et al. (2018) investigated the impact of smartphone use on respiratory muscle
strength in healthy young adults. The study found that individuals who used smartphones for
more than 4 hours per day had reduced respiratory muscle strength, as compared to those who
used smartphones for less than 2 hours per day. The authors suggested that prolonged smartphone
use may reduce respiratory muscle strength by causing muscle fatigue and reducing
diaphragmatic excursion.

A study by Ozkaya et al. (2019) investigated the impact of smartphone use on pulmonary
function and respiratory symptoms in university students. The study found that individuals who
used smartphones for more than 5 hours per day had a higher prevalence of respiratory
symptoms, such as cough, phlegm, shortness of breath, and reduced pulmonary function, as
compared to those who used smartphones for less than 2 hours per day. The authors suggested
that prolonged smartphone use may contribute to respiratory problems by increasing exposure to
air pollutants and reducing lung capacity.

Another study by Gao et al. (2021) investigated the impact of smartphone use on respiratory
health in university students during the COVID-19 pandemic. The study found that individuals
who used smartphones for more than 6 hours per day had a higher prevalence of respiratory
symptoms, such as cough and phlegm, and reduced pulmonary function, as measured by FVC
and FEV1, as compared to those who used smartphones for less than 3 hours per day. The authors
suggested that prolonged smartphone use during the pandemic may have contributed to
respiratory problems by increasing sedentary behaviour and reducing physical activity.

A study by Choi et al. (2017) investigated the impact of smartphone use on respiratory symptoms
and pulmonary function in young adults with asthma. The study found that individuals who used
smartphones for more than 2 hours per day had a higher prevalence of respiratory symptoms and
reduced pulmonary function, as compared to those who used smartphones for less than 1 hour per

27
day. The authors suggested that prolonged smartphone use may aggravate asthma symptoms by
increasing exposure to allergens and pollutants and reducing lung function.

Another study by Cho et al. (2019) investigated the relationship between smartphone use and
respiratory symptoms in college students. The study found that individuals who used
smartphones for more than 4 hours per day had a higher prevalence of respiratory symptoms,
such as cough, shortness of breath, and chest tightness, as compared to those who used
smartphones for less than 2 hours per day. The authors suggested that prolonged smartphone use
may contribute to respiratory symptoms by increasing exposure to pollutants and reducing lung
function.

28
 CHAPTER 3

MATERIALS & METHODS

3.1 Study Design:

It was an observational cross-sectional survey.

3.2 Study Setting:

Data was collected from young adults belonging to different cities in Punjab.

3.3 Study Duration:

This study was completed within 6 months after approval of synopsis.

3.4 Sample Size:

Sample size calculated with epi-tools was 100.

Estimated Proportion 0.9

Desired precision of estimate 0.08
Confidence level 0.95
Population size 3000

3.5 Sampling Technique

The sampling technique used in this study was Convenience sampling technique.

3.6 Participation Selection:

3.6.1 Inclusion criteria:
• Age: 18 to 30 years

• Both males and females.

29
 • Currently having good physical or mental health.

• 3.6.2 Exclusion criteria:

• Any physical disability.

• Any anatomical bony deformity of lower limbs or upper limbs

• Person with any spinal structural problems, neurological disorders, a history of cervical
fracture, bone cancer, or thoracic surgery.

• Person with any psychological illness.

3.7 Data Collection Procedures:

A total of 100 participants that met the inclusion criteria were selected and interviewed to fill the

SAS-SV Questionnaire to measure smartphone addiction of participants, later on Pulmonary

function tests i.e. Incentive Spirometry, peak flow meter readings were recorded and CVA was

measured by using photographic method. The eligible participants willingly signed consent form

and the rights of participants were protected.

3.8 Tools/ Tests for Data Collection:

There were four main sources for data collection:

1. SAS-SV

2. Photographic method for CVA measurement

3. Incentive Spirometer

4. Peak Flow meter

The Smartphone addiction scale (Short version) has been recommended as a cost-effective
method to assess addiction of smartphone. Several studies validating the SAS-SV have been
conducted with differing results. Smartphone addiction was measured separately for every
participant. Individuals are scored based on their responses, with a higher score indicating a

30
greater severity of smartphone addiction. A score of 32 or higher is generally considered to
indicate problematic smartphone use.

The craniovertebral angle (CVA) is the angle formed between a horizontal line drawn through the
C7 vertebra (the vertebra at the base of the neck) and a line drawn from the tragus of the ear to
the C7 vertebra. It is a measure of the forward head posture and is commonly used to assess the
cervical spine alignment.  CVA less than 48–50 is known as Forward head posture. One method
for measuring the CVA is through the use of photographs. This method involves taking a lateral
photograph of the individual, in which the individual is in sitting position without any support
and their head positioned in a neutral position. The photograph is then imported into image
analysis software, and a horizontal line is drawn through the C7 vertebra, and a line is drawn
from the tragus of the ear to the C7 vertebra. The angle between these two lines is then measured,
and this measurement is used to determine the CVA angle. This method has been shown to be
reliable and valid for measuring the CVA angle, and it is a convenient and non-invasive way to
assess cervical spine alignment.

Incentive spirometry is a medical device used to help patients improve their lung function by
promoting deep breathing and preventing atelectasis (collapse of small airways in the lungs). It
consists of a plastic chamber with a mouthpiece and a series of coloured balls or a digital display
that provides visual feedback to the patient. During use, the patient inhales through the
mouthpiece, which creates a flow of air that raises the balls or activates the digital display. The
patient is instructed to inhale as deeply as possible, aiming to raise the balls or achieve a target
volume on the digital display. The patient then holds their breath for several seconds before
exhaling slowly.

31
 Fig 1: Protocol for using Incentive spirometer

Peak expiratory flow meter (PEFM) is a handheld device used to measure the maximum flow rate
of air that a person can exhale forcefully and rapidly after taking a deep breath. It is commonly
used to monitor lung function in people with asthma, chronic obstructive pulmonary disease
(COPD), and other respiratory conditions. To use a PEFM, the patient takes a deep breath and
then exhales forcefully into the device. The PEFM measured the maximum flow rate of air in
milliliters per second (ml/sec), which reflected the degree of airway obstruction or narrowing.
PEFM measurements can help patients and healthcare providers monitor changes in lung function
over time, identify triggers or exacerbations of respiratory symptoms, and adjust medication
regimens as needed. Regular use of a PEFM can also help patients better manage their condition
and improve adherence to treatment.

32
 Fig 2: Protocol for using PEFM

3.9 Data Analysis:

Data was analysed using statistical package for social sciences (SPSS) V 21. Descriptive
statistics, percentages and frequency tables were defined. Bar or pie chart was plotted. Pearson
correlation was applied to correlate SAS-SV readings with CVA, Spirometer readings, FEV1,
FVC, FEV1/FVC. P score less than 0.05 was set as statistically significant.

33
 CHAPTER 4:

RESULTS

The mean score of smartphone addiction among the study participants was 47.07 ± 9.757.
Majority of participants addicted to smartphone were 79%.(Fig.3)

Fig 3: Smartphone addiction in participants

Among the study participants, only 21% were not addicted to smartphone and they were found to
use smartphone for less than 4 hours, whereas the vast majority 79% were addicted to their
smartphones and they were found to use their smartphone for 4 or more hours. These findings
suggest that prolonged smartphone usage is a common practice among the study population that
can lead to smartphone addiction.

34
 80
70 67%

60

Percentage %
50
40 33%
30
20
10
0
Compromised Normal

Incentive Spirometer Score

Fig 4: Incentive Spirometer score

The distribution of incentive spirometer readings among the study participants. The chart
indicates that a significant proportion 40% of participants had low incentive spirometer readings,
while 27% demonstrated moderate incentive spirometer readings of 900. Only 33% exhibited
high incentive spirometer readings. These findings provide important insights into the respiratory
health of the study population. These findings elaborate that 67% people were having
compromised pulmonary functions whereas 33% people were having normal pulmonary
functions.(Fig.4)

35
 70

60
Craniovertebral angle (CVA)

50

40

30

20

10

0
10 15 20 25 30 35 40 45 50 55 60

Smartphone addiction score

Fig 5: Relationship between Craniovertebral angle and Smartphone addiction

score

The graph illustrates a negative correlation between these variables, wherein an increase in
smartphone addiction is associated with a decrease in the craniovertebral
angle(r=-.455,p=.000)and a subsequent increase in forward head posture. These findings
highlight the potential impact of prolonged smartphone usage on postural alignment and neck
health, underscoring the importance of appropriate smartphone usage and posture correction
practices.(Fig.5)

36
 1400

1200
Incentive spirometer score (ml/sec)
1000

800

600

400

200

0
10 15 20 25 30 35 40 45 50 55 60

Smartphone addiction score

Fig 6: Relationship between incentive spirometer score and Smartphone addiction score

The graph indicates a negative correlation between these variables, with an increase in
smartphone addiction associated with a decrease in the inspiratory reserve
volume(r=-.591,p=.000). These findings suggest that prolonged smartphone usage may have a
negative impact on respiratory functions and highlight the importance of appropriate smartphone
usage practices and respiratory health promotion.(Fig.6)

37
 500

450
Forced Expiratory Volume in 1 sec (L/min)

400

350

300

250

200

150

100

50

0
10 15 20 25 30 35 40 45 50 55 60

Smartphone addiction score

Fig 7: Relationship between Forced expiratory volume in one second and Smartphone
addiction score

The graph illustrates a negative correlation between these variables, indicating that an increase in
smartphone addiction is associated with a decrease in the forced expiratory volume in one
second(r=-.358,p=.285). These findings suggest that prolonged smartphone usage may have a
negative impact on respiratory functions and highlights the need for further investigation into the
potential health effects of excessive smartphone usage.(Fig.7)

38
 700

600
Forced Vital capacity (L/min)

500

400

300

200

100

0
10 15 20 25 30 35 40 45 50 55 60

Smartphone addiction score

Fig 8: Relationship between forced vital capacity and Smartphone addiction score

The graph demonstrates a negative correlation between these variables, with an increase in
smartphone addiction associated with a decrease in forced vital capacity(r=-.404,p=.112). These
findings suggest that prolonged smartphone usage may have a negative impact on respiratory
function and highlight the importance of appropriate smartphone usage practices and respiratory
health promotion.(Fig.8)

39
 100

90

80

70

60
FEV1/FVC %

50

40

30

20

10

0
10 15 20 25 30 35 40 45 50 55 60

Smartphone addiction score

Fig 9: Relationship between FEV1/FVC and Smartphone addiction score

The graph illustrates a negative correlation between these variables, with an increase in
smartphone addiction associated with a decrease in the FEV1/FVC ratio(r=-.103,p=.008). These
findings suggest that prolonged smartphone usage may have a negative impact on respiratory
function and highlight the need for further investigation into the potential health effects of
excessive smartphone usage on lung function.(Fig.9)

40
Table 1: Correlation between level of smartphone addiction, CVA, Incentive spirometer
readings, FEV1, FVC, and FEV1/FVC

Correlations Variable Pearson P-Value

Correlation

Level of addiction to Craniovertebral angle -.455** .000

Smartphone

Level of addiction to Incentive spirometer -.591** . 000

Smartphone score

Level of addiction to Forced expiratory -.358** . 285

Smartphone Volume in 1 sec

Level of addiction to Forced vital capacity -.404** . 112

Smartphone

Level of addiction to FEV1/FVC -.103** . 008

Smartphone

Table 1 presents the results of Pearson correlation analysis between smartphone addiction and
four respiratory function readings. The correlation coefficient between smartphone addiction and
CVA was moderately negative and statistically significant (r=-.455, p<0.05), indicating that an
increase in smartphone addiction is associated with a decrease in CVA. Similarly, the correlation
coefficient between smartphone addiction and incentive spirometer readings was moderately
negative and statistically significant (r=-.591, p<0.05), indicating that an increase in smartphone
addiction is associated with a decrease in incentive spirometer readings. The correlation
coefficients between smartphone addiction and FEV1 and FVC were both low negative and
statistically significant (r=-.358 and r=-.404, respectively, p<0.05), suggesting that an increase in
smartphone addiction is associated with a decrease in both FEV1 and FVC. Lastly, the correlation
coefficient between smartphone addiction and FEV1/FVC was very low negative and statistically
significant (r=-.103, p<0.05), indicating that an increase in smartphone addiction is associated
with a decrease in the ratio of FEV1/FVC.

41
CHAPTER 5
DISCUSSION

The present study contributes to the growing body of evidence indicating a link between
smartphone addiction,CVA, and pulmonary function in young adults. Prior research has shown
that prolonged smartphone use can lead to changes in muscle activity, specifically increased
activation of the sternocleidomastoid muscle and reduced activation of the deep neck flexor
muscles, resulting in forward head posture and associated health issues. To focus on healthy
individuals and minimize the influence of various health conditions on CVA and pulmonary
function, this study only included participants without medical complications such as deformity,
cancer, or joint problems that become more common with age. Smartphone addiction was
assessed using the smartphone addiction scale, revealing that participants who used smartphones
for four hours or more per day exhibited greater addiction compared to those who used
smartphones for less than four hours.

CVA was evaluated through a photographic method, while pulmonary function was measured
using an incentive spirometer and peak expiratory flow meter. The study calculated the Pearson
correlation between smartphone addiction and four readings: CVA, incentive spirometer
readings, FEV1, FVC, and FEV1/FVC ratio. The results indicated a moderate negative
correlation between smartphone addiction and CVA, incentive spirometer readings, and FVC,
implying that increased smartphone addiction was associated with decreased values for these
measures. The correlation between smartphone addiction and FEV1 was low and negative,
suggesting a slight decrease in FEV1 with increased smartphone addiction. Similarly, the
correlation between smartphone addiction and FEV1/FVC was very low and negative, indicating
a slight decrease in this ratio with increased smartphone addiction.

Kim et al. (2016) investigated the effects of smartphone use on upper extremity muscle activity
and pain threshold, revealing that prolonged smartphone use led to increased muscle activity in
the neck and shoulder area, resulting in muscle fatigue and discomfort. This finding has
implications for cervical posture. Lee et al. (2017) explored the relationship between smartphone
use and subjective musculoskeletal symptoms among university students, finding a significant

42
association between smartphone use and musculoskeletal symptoms, particularly in the neck and
shoulder region, with prolonged forward head posture during smartphone use considered a
contributing factor. Xie et al. (2017) conducted a meta-analysis on risk factors for neck pain
among computer-using workers, which indicated that smartphone use, along with other
computer-related activities, was a risk factor for the development of neck pain and poor cervical
posture. The present study aligns with these findings by suggesting that prolonged smartphone
use may contribute to poor cervical posture and reduced craniovertebral angle. Additionally, it
supports the notion of compromised pulmonary function due to prolonged smartphone usage.

Suh et al. (2018) investigated the effects of smartphone usage time on posture and respiratory
function, finding that increased smartphone usage time was associated with forward head posture
and reduced respiratory function, potentially impacting pulmonary function in young adults. The
present study corroborates these findings by suggesting that exceeding four hours of smartphone
usage may lead to poor cervical posture and compromised pulmonary function in young adults.
Xie et al. (2020) explored the association between mobile phone use and pulmonary function
through a systematic review and meta-analysis, demonstrating that prolonged mobile phone use
was linked to decreased pulmonary function, including reduced FVC and FEV1. The present
study supports these findings by revealing that prolonged smartphone usage may contribute to
poor cervical posture and compromised pulmonary function, and as smartphone usage duration
increases, there may be a tendency for decreased FEV1 and FVC.

Overall, the present study suggests that smartphone addiction may have negative effects on CVA
and pulmonary function in young adults. Further research is necessary to fully comprehend the
mechanisms underlying these relationships

43
Conclusion:

We found that Smartphone addiction may negatively impact cervical posture and pulmonary
functions.

Limitations:

• The findings of the study cannot be generalized due to small sample size.

• Young adults were the only population studied.

CHAPTER 6
44
 References:

AHMED, S., MISHRA, A., AKTER, R., SHAH, M. H. & SADIA, A. A. 2022. Smartphone addiction and its
impact on musculoskeletal pain in neck, shoulder, elbow, and hand among college going
students: a cross-sectional study. Bulletin of Faculty of Physical Therapy, 27, 5.
AKODU, A. K., AKINBO, S. R. & YOUNG, Q. O. 2018. Correlation among smartphone addiction,
craniovertebral angle, scapular dyskinesis, and selected anthropometric variables in
physiotherapy undergraduates. Journal of Taibah University Medical Sciences, 13, 528-534.
ALONAZI, A., ALMUTAIRI, W., BAINS, G., DAHER, N. & ALISMAIL, A. 2021. Effects of smartphone addiction
on children’s lung function. Pediatrics International, 63, 323-330.
AYLOTT, C. E. W., PUNA, R., ROBERTSON, P. A. & WALKER, C. 2012. Spinous process morphology: the
effect of ageing through adulthood on spinous process size and relationship to sagittal alignment.
European Spine Journal, 21, 1007-1012.
BARNES, P. J., SHAPIRO, S. D. & PAUWELS, R. 2003. Chronic obstructive pulmonary disease: molecular
and cellularmechanisms. European Respiratory Journal, 22, 672-688.
BATES, D., BOUCOT, N. G. & DORMER, A. 1955. The pulmonary diffusing capacity in normal subjects. The
Journal of Physiology, 129, 237.
BEN-TAL, A. 2006. Simplified models for gas exchange in the human lungs. Journal of theoretical biology,
238, 474-495.
BOUHUYS, A. & JONSON, B. 1967. Alveolar pressure, airflow rate, and lung inflation in man. Journal of
Applied Physiology, 22, 1086-1100.
BOZKURT, B. & MANN, D. L. 2003. Shortness of breath. Circulation, 108, e11-e13.
BRADLEY, H. & ESFORMES, J. D. 2014. Breathing pattern disorders and functional movement.
International journal of sports physical therapy, 9, 28.
BUKE, M., EGESOY, H. & UNVER, F. 2021. The effect of smartphone addiction on physical activity level in
sports science undergraduates. Journal of bodywork and movement therapies, 28, 530-534.
CHA, S.-S. & SEO, B.-K. 2018. Smartphone use and smartphone addiction in middle school students in
Korea: Prevalence, social networking service, and game use. Health psychology open, 5,
2055102918755046.
CLARK, C. R. & BENZEL, E. C. 2005. The cervical spine, Lippincott Williams & Wilkins.
COOPER, B. G. 2011. An update on contraindications for lung function testing. Thorax, 66, 714-723.
COTES, J. E., CHINN, D. J. & MILLER, M. R. 2009. Lung function: physiology, measurement and application
in medicine, John Wiley & Sons.
CRAPO, R. O. 1994. Pulmonary-function testing. New England Journal of Medicine, 331, 25-30.
CROSBY, E. T. & LUI, A. 1990. The adult cervical spine: implications for airway management. Canadian
Journal of Anesthesia/Journal canadien d'anesthésie, 37, 77-93.
CUADROS, C. L., DRISCOLL, C. & ROTHKOPF, D. M. 1995. The anatomy of the lower serratus anterior
muscle: a fresh cadaver study. Plastic and reconstructive surgery, 95, 93-7; discussion 98.
CUÉLLAR, J. M. & LANMAN, T. H. 2017. “Text neck”: an epidemic of the modern era of cell phones? The
Spine Journal, 17, 901-902.
DE PASQUALE, C., SCIACCA, F. & HICHY, Z. 2017. Italian validation of smartphone addiction scale short
version for adolescents and young adults (SAS-SV). Psychology, 8, 1513-1518.
EDELSON, J. & TAITZ, C. 1992. Anatomy of the coraco-acromial arch. Relation to degeneration of the
acromion. The Journal of Bone and Joint Surgery. British Volume, 74, 589-594.
EDMONDSTON, S. & SINGER, K. 1997. Thoracic spine: anatomical and biomechanical considerations for
manual therapy. Manual therapy, 2, 132-143.

45
EMANUEL, R., BELL, R., COTTON, C., CRAIG, J., DRUMMOND, D., GIBSON, S., HARRIS, A., HARRIS, M.,
HATCHER-VANCE, C. & JONES, S. 2015. The truth about smartphone addiction. College Student
Journal, 49, 291-299.
ENRIGHT, P. L., LEBOWITZ, M. D. & COCKROFT, D. W. 2012. Physiologic measures: pulmonary function
tests. American journal of respiratory and critical care medicine.
FIELDING, J. W. 1964. Normal and selected abnormal motion of the cervical spine from the second
cervical vertebra to the seventh cervical vertebra based on cineroentgenography. JBJS, 46, 1779-
1781.
FOLTRAN-MESCOLLOTTO, F., GONÇALVES, É. B., CASTRO-CARLETTI, E. M. D., OLIVEIRA, A. B., PELAI, E. B.
& RODRIGUES-BIGATON, D. 2021. Smartphone addiction and the relationship with head and neck
pain and electromiographic activity of masticatory muscles. Work, 68, 633-640.
FREEMAN, M. 2008. Rhomboid proteases and their biological functions. Annual review of genetics, 42,
191-210.
GADA, J. & OBEROI, M. 2018. Impact of smartphone addiction on cervical pain, cervical lordosis and
pectoralis minor muscle in young adults. WAY, 132, 58.172.
GEETE, D. B., SETHIYA, A., SHETYE, J. V., KAMAT, M. N. & IYER, S. 2021. Correlation of smartphone usage
with functional capacity in young adults. Physiotherapy-The Journal of Indian Association of
Physiotherapists, 15, 93.
GONZALEZ, H. E. & MANNS, A. 1996. Forward head posture: its structural and functional influence on the
stomatognathic system, a conceptual study. Cranio®, 14, 71-80.
GRIMMER-SOMERS, K., MILANESE, S. & LOUW, Q. 2008. Measurement of cervical posture in the sagittal
plane. Journal of manipulative and physiological therapeutics, 31, 509-517.
HAMID, Q. & TULIC, M. 2009. Immunobiology of asthma. Annual review of physiology, 71, 489-507.
HANSEN, J. E., SUN, X.-G. & WASSERMAN, K. 2007. Spirometric criteria for airway obstruction: Use
percentage of FEV1/FVC ratio below the fifth percentile, not< 70%. Chest, 131, 349-355.
HANTEN, W. P., LUCIO, R. M., RUSSELL, J. L. & BRUNT, D. 1991. Assessment of total head excursion and
resting head posture. Archives of physical medicine and rehabilitation, 72, 877-880.
HILL, N. S. 2006. Pulmonary rehabilitation. Proceedings of the American Thoracic Society, 3, 66-74.
HINIKER, A., SOBEL, K., SUH, H., SUNG, Y.-C., LEE, C. P. & KIENTZ, J. A. Texting while parenting: How adults
use mobile phones while caring for children at the playground. Proceedings of the 33rd annual
ACM conference on human factors in computing systems, 2015. 727-736.
HODSON, M., BUSH, A. & GEDDES, D. 2012. Cystic fibrosis, CRC press.
HOLLINGSWORTH, H. M. 1987. Wheezing and stridor. Clinics in chest medicine, 8, 231-240.
JANDA, V., FRANK, C. & LIEBENSON, C. 1996. Evaluation of muscular imbalance. Rehabilitation of the
spine: a practitioner's manual, 6, 97-112.
JOHNSON, G., BOGDUK, N., NOWITZKE, A. & HOUSE, D. 1994. Anatomy and actions of the trapezius
muscle. Clinical biomechanics, 9, 44-50.
JOHNSON, J. 2015. Postural correction, Human Kinetics.
JULL, G. A., O'LEARY, S. P. & FALLA, D. L. 2008. Clinical assessment of the deep cervical flexor muscles: the
craniocervical flexion test. Journal of manipulative and physiological therapeutics, 31, 525-533.
KEE, I.-K., BYUN, J.-S., JUNG, J.-K. & CHOI, J.-K. 2016. The presence of altered craniocervical posture and
mobility in smartphone-addicted teenagers with temporomandibular disorders. Journal of
physical therapy science, 28, 339-346.
KRAMER, I., BAUER, S. & MATEJCEK, A. 2022. Automated Detection of Ear Tragus and C7 Spinous Process
in a Single RGB Image—A Novel Effective Approach. BioMedInformatics, 2, 318-331.
KWON, M., LEE, J.-Y., WON, W.-Y., PARK, J.-W., MIN, J.-A., HAHN, C., GU, X., CHOI, J.-H. & KIM, D.-J. 2013.
Development and validation of a smartphone addiction scale (SAS). PloS one, 8, e56936.

46
LABIB, M. 2022. mechanical neck pain affects on pulmonary functions in smart phone addicted
population. Egyptian Journal of Physical Therapy, 12, 38-42.
LAU, H. M. C., CHIU, T. T. W. & LAM, T.-H. 2009. Clinical measurement of craniovertebral angle by
electronic head posture instrument: a test of reliability and validity. Manual therapy, 14, 363-
368.
LEA, R. D. & GERHARDT, J. J. 1995. Range-of-motion measurements. JBJS, 77, 784-798.
LEE, J. & SEO, K. 2014. The comparison of cervical repositioning errors according to smartphone addiction
grades. Journal of physical therapy science, 26, 595-598.
LI, C., ZHAO, Y., YU, Z., HAN, X., LIN, X. & WEN, L. 2022. Sagittal imbalance of the spine is associated with
poor sitting posture among primary and secondary school students in China: a cross-sectional
study. BMC Musculoskeletal Disorders, 23, 98.
MAC HALE, E., GREENE, G., MULVEY, C., MOKOKA, M. C., VAN BOVEN, J. F., CUSHEN, B., SULAIMAN, I.,
BRENNAN, V., LOMBARD, L. & WALSH, J. 2023. Use of digital measurement of medication
adherence and lung function to guide the management of uncontrolled asthma (INCA Sun): a
multicentre, single-blinded, randomised clinical trial. The Lancet Respiratory Medicine.
MAHLER, D. A. 1998. Pulmonary rehabilitation. Chest, 113, 263S-268S.
MAUREL, W. 1999. 3D modeling of the human upper limb including the biomechanics of joints, muscles
and soft tissues. EPFL.
MUSTAFAOGLU, R., YASACI, Z., ZIREK, E., GRIFFITHS, M. D. & OZDINCLER, A. R. 2021. The relationship
between smartphone addiction and musculoskeletal pain prevalence among young population: a
cross-sectional study. The Korean journal of pain, 34, 72-81.
PARK, J., KIM, J., KIM, J., KIM, K., KIM, N., CHOI, I., LEE, S. & YIM, J. 2015a. The effects of heavy
smartphone use on the cervical angle, pain threshold of neck muscles and depression. Advanced
Science and Technology Letters, 91, 12-17.
PARK, J., KIM, K., KIM, N., CHOI, I., LEE, S., TAK, S. & YIM, J. 2015b. A comparison of cervical flexion, pain,
and clinical depression in frequency of smartphone use. International Journal of Bio-Science and
Bio-Technology, 7, 183-90.
PAVIA, L., CAVANI, P., DI BLASI, M. & GIORDANO, C. 2016. Smartphone Addiction Inventory (SPAI):
Psychometric properties and confirmatory factor analysis. Computers in Human Behavior, 63,
170-178.
PEARSAII, D. & REID, J. 1992. Line of gravity relative to upright vertebral posture. Clinical Biomechanics, 7,
80-86.
PELKONEN, M., NOTKOLA, I.-L., LAKKA, T., TUKIAINEN, H. O., KIVINEN, P. & NISSINEN, A. 2003. Delaying
decline in pulmonary function with physical activity: a 25-year follow-up. American journal of
respiratory and critical care medicine, 168, 494-499.
PIIPER, J. 1982. Respiratory gas exchange at lungs, gills and tissues: mechanisms and adjustments.
Journal of Experimental Biology, 100, 5-22.
POUSHTER, J. 2016. Smartphone ownership and internet usage continues to climb in emerging
economies. Pew research center, 22, 1-44.
RAHERISON, C. & GIRODET, P. 2009. Epidemiology of COPD. European Respiratory Review, 18, 213-221.
RANU, H., WILDE, M. & MADDEN, B. 2011. Pulmonary function tests. Ulster Med J, 80, 84-90.
REHABILITATION, B. T. S. S. O. C. S. O. P. 2001. Pulmonary rehabilitation. Thorax, 56, 827-834.
RESTREPO, R. D., WETTSTEIN, R., WITTNEBEL, L. & TRACY, M. 2011. Incentive spirometry: 2011.
Respiratory care, 56, 1600-1604.
SCHOMACHER, J. & FALLA, D. 2013. Function and structure of the deep cervical extensor muscles in
patients with neck pain. Manual therapy, 18, 360-366.

47
SELVAGANAPATHY, K., RAJAPPAN, R. & DEE, T. H. 2017. The effect of smartphone addiction on
craniovertebral angle and depression status among university students. International Journal of
Intagrative Medical Sciences, 4, 537-542.
SHOUKAT, S. 2019. Cell phone addiction and psychological and physiological health in adolescents. EXCLI
journal, 18, 47.
SODEYAMA, Y., MIZUUCHI, I., YOSHIKAI, T., NAKANISHI, Y. & INABA, M. A shoulder structure of muscle-
driven humanoid with shoulder blades. 2005 IEEE/RSJ International Conference on Intelligent
Robots and Systems, 2005. IEEE, 4028-4033.
SOLOW, B. & SANDHAM, A. 2002. Cranio‐cervical posture: a factor in the development and function of
the dentofacial structures. The European Journal of Orthodontics, 24, 447-456.
SPRUIT, M. A. 2014. Pulmonary rehabilitation. European Respiratory Review, 23, 55-63.
STÄRK, K. D. 2000. Epidemiological investigation of the influence of environmental risk factors on
respiratory diseases in swine—a literature review. The Veterinary Journal, 159, 37-56.
TANG, J. W. & SETTLES, G. S. 2008. Coughing and aerosols. New England Journal of Medicine, 359, e19.
TING, C. H. & CHEN, Y. Y. 2020. Smartphone addiction. Adolescent addiction. Elsevier.
UNGER, S. A. & BOGAERT, D. 2017. The respiratory microbiome and respiratory infections. Journal of
Infection, 74, S84-S88.
WANGER, J., CLAUSEN, J., COATES, A., PEDERSEN, O., BRUSASCO, V., BURGOS, F., CASABURI, R., CRAPO,
R., ENRIGHT, P. & VAN DER GRINTEN, C. 2005. Standardisation of the measurement of lung
volumes. European respiratory journal, 26, 511-522.
WARTELLA, E., RIDEOUT, V., MONTAGUE, H., BEAUDOIN-RYAN, L. & LAURICELLA, A. 2016. Teens, health
and technology: A national survey. Media and communication, 4, 13-23.
WARTZOK, D. 2009. Breathing. Encyclopedia of marine mammals. Elsevier.

48
 Appendix I: ENGLISH CONSENT FORM

The study you are about to participate is “Impact of smartphone use on

cervical posture and pulmonary function in young adults”

The study has no potential harm to participants. All data collected from you will be coded in

order to protect your identity, and should not be disclosed to anyone. Following the study there

will be no way to connect your name with your data. Your answers to the questions will not

affect the quality of education given to you. Any additional information about the study results

will be provided to you at its conclusion, upon your request.

You are free to withdraw from the study at any time. You agree to participate, indicating that you

have read and understood the nature of the study, and that all your inquiries concerning the

activities have been answered to your satisfaction.

Name: _______________________ Date: _________________

Signature: ________________________

49
‫‪APPENDIX II: URDU CONSENT FORM‬‬

‫رضا مندی فار م‬

‫میں _________________________ تصدیق کرتا‪ /‬کرتی ہوں کہ‬

‫نے‬ ‫طلبات‬

‫اپنی تحقیق‬

‫‪RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND MUSCLE FLEXIBILITY IN‬‬

‫‪YOUNG ADULTS‬‬

‫زیرنگران ڈاکٹر مصطفی قمر ‪ ،‬کے متعلق بتا دیا ہے۔ مجھے… اس تحقیق کی نوعیت‪ ،‬مقاصد‪ ،‬احداف‪ ،‬توقعات‪ ،‬فوائد اور خطرات‬

‫کے متعلق ساری معلومات فراہم کر دی گئی ہیں ۔‬

‫‪50‬‬
 Impact of smartphone use on cervical posture and pulmonary
function in young adults

Name: _____________
City: ______________
Gender:
Male
Female
Age: ___________
Profession: _____________

CVA: _________

Spirometer reading: _________

FEV1: ___________

FVC: ____________

What make/model is your smartphone? ____________

Smartphone use probably:

Significantly reduces creativity

Somewhat reduces creativity
Has no effect on creativity
Somewhat increases creativity
Significantly increases creativity

Are you suffering from any illness/disease now? __________

I use smart phone for almost ____ hours a day: ___________

51
 (SAS-SV)

01- I miss work that I planned, due to smartphone use:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

02- I have a hard time concentrating in class, while doing assignments, or while working due to
smartphone use:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

03- I feel pain in my wrists or at the back of my neck while using a smartphone:

Strongly Disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

04- I wouldn't be able to stand not having a smartphone:

Strongly disagree
Disagree
Weakly disagree

52
 Weakly agree
Agree
Strongly agree

05- I feel impatient and fretful when I am not holding my smartphone:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

06- I have my smartphone on my mind even when I am not using it:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

07- I would never give up using my smartphone even when my daily life were greatly affected
by it:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

08- I constantly check my smartphone so as not to miss conversations between other people on
Twitter, Facebook, Snapchat, Instagram, Tik Tok, or other social media:

53
 Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

09- I use my smartphone longer than I had intend:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

10- People around me tell me that I use my smartphone too much:

Strongly disagree
Disagree
Weakly disagree
Weakly agree
Agree
Strongly agree

54